This document discusses achalasia, a rare disorder where the lower esophagus fails to relax and allow food to pass into the stomach. It defines achalasia, lists its causes as damage to nerves in the esophagus, and discusses its clinical manifestations such as difficulty swallowing and food returning to the mouth. The document outlines the diagnosis, medical management including balloon dilation and Botox injections, and nursing care for patients with achalasia which focuses on positioning during eating and monitoring for complications.

1. Achalasia
Awal Sher Khan
Lecturer INS-KMU

2. Objectives
By the end of this session the students will be able to:
• Define achalasia
• Discuss the causes and risk factors of achalasia
• Explain pathophysiology and clinical manifestation of
achalasia
• Discuss complication of achalasia
• Discuss the diagnosis and medical management of
achalasia
• Apply nursing management for patient with achalasia

3. Achalasia
A condition in which the muscles of the lower
part of the esophagus fail to relax, preventing
food from passing into the stomach.
It is a rare disorder that makes it difficult for
food and liquid to pass from the swallowing
tube connecting your mouth and stomach
(esophagus) into your stomach.

4. Cont…
Achalasia occurs when nerves in the esophagus
become damaged. As a result, the esophagus
become paralyzed and dilated over time and
eventually loses the ability to squeeze food
down into the stomach.
Food then collects in the esophagus,
sometimes fermenting and washing back up
into the mouth, which can taste bitter.

5. Cont…
Some people mistake this for esophageal reflux
disease (GERD).
However, in achalasia the food is coming from
esophagus, whereas in GERD the materials
come from the stomach.

7. Causes
• The exact causes of achalasia is poorly
understood. Researcher suspect it may be
caused by a loss of nerve cell in the
esophagus.
• Viral infection or autoimmune responses have
been suspected
• Very rarely it may be caused by an inherited
genetic disorder or infection

8. Cont…
• However, a small proportion occurs secondary
to other conditions, such as esophageal
cancer or Chagas disease ( an infectious
disease common in south america).

9. Risk factors
• It occurs in any age but most often between 30
and 60.
• Men and women are equally at risk
• Having certain genes
• Having problems with immune system
• Having Herpes simplex virus or other viral
infections
• Having Chagas disease. This is an infection cause
by parasite.

10. pathophysiology

11. Cont…
• Achalasia is characterized by lower esophageal
sphincter pressure, decreased or absent
peristalsis in the distal portion of the
esophagus and lack of LES relaxation in
response to swallowing.

12. Clinical manifestation
• Trouble swallowing, both liquid and solid
• Chest pain or discomfort
• Weight loss
• Food or liquid come back up into throat
(regurgitation), especially when you are lying
down; its often mix with saliva and mucous.
• Food; food seems to hang up in your chest.
• heartburn

13. Cont…
• Coughing at night
• Pneumonia (from aspiration of food into the
lungs)
• Belching
• Vomiting

14. Complications
• bronchitis,
• pneumonia, or
• chronic lung disease.
• The retained food can also cause chronic
irritation of the esophageal lining, sometimes
with fungal infections

15. Cont…
• Poor nutrition may lead to weight loss or
malnutrition.
• There are also a small increased risk of
esophageal cancer.
• Esophageal perforation
• Aspiration pneumonia

16. Diagnosis
• Achalasia is a rare condition, it can be confused
with more common esophageal problems, such
as GERD. Because of this patients can be
misdiagnosed for many months or years
• If patient have constant trouble swallowing, they
should be investigated for achalasia.
• Upper endoscopy: this test allow the doctor to
examine the lining of esophagus, stomach and
duodenum.

17. Cont…
• Esophageal manometry: this test can find out
if peristalsis is working and if the LES is
relaxing.
• Esophagram: this is an X-ray study of the
esophagus and stomach

21. Medical management
• Nonsurgical treatment
• Nonsurgical options include:
• Pneumatic dilation. A balloon is inserted by
endoscopy into the center of the esophageal
sphincter and inflated to enlarge the opening.
This outpatient procedure may need to be
repeated if the esophageal sphincter doesn't stay
open. Nearly one-third of people treated with
balloon dilation need repeat treatment within
five years. This procedure requires sedation.

22. Cont…
• Botox (botulinum toxin type A). This muscle relaxant
can be injected directly into the esophageal sphincter
with an endoscopic needle. The injections may need to
be repeated , and repeat injections may make it more
difficult to perform surgery later if needed.
• Botox is generally recommended only for people who
aren't good candidates for pneumatic dilation or
surgery due to age or overall health. Botox injections
typically do not last more than six months. A strong
improvement from injection of Botox may help confirm
a diagnosis of achalasia.

23. Cont…
• Medication. Your doctor might suggest muscle
relaxants such as nitroglycerin (Nitrostat) or
nifedipine (Procardia) before eating.
• These medications have limited treatment
effect and severe side effects.
• Medications are generally considered only if
you're not a candidate for pneumatic dilation
or surgery, and Botox hasn't helped.
• This type of therapy is rarely indicated.

24. Cont…
• Surgery
• Surgical options for treating achalasia include:
• Heller myotomy. The surgeon cuts the muscle at the lower end of the
esophageal sphincter to allow food to pass more easily into the stomach.
• The procedure can be done noninvasively (laparoscopic Heller myotomy).
Some people who have a Heller myotomy may later develop
gastroesophageal reflux disease (GERD).
• To avoid future problems with GERD, a procedure known as fundoplication
might be performed at the same time as a Heller myotomy.
• In fundoplication, the surgeon wraps the top of your stomach around the
lower esophagus to create an anti-reflux valve, preventing acid from
coming back (GERD) into the esophagus.
• Fundoplication is usually done with a minimally invasive (laparoscopic)
procedure.

25. Cont…
• Peroral endoscopic myotomy (POEM). In
the POEM procedure, the surgeon uses an endoscope
inserted through your mouth and down your throat to
create an incision in the inside lining of your
esophagus. Then, as in a Heller myotomy, the surgeon
cuts the muscle at the lower end of the esophageal
sphincter.
• POEM may also be combined with or followed by later
fundoplication to help prevent GERD. Some patients
who have a POEM and develop GERD after the
procedure are treated with daily oral medication.

26. Nursing diagnosis
• Dysphagia(difficulty in swallowing) related to
aperistalsis.
• Backflow of food related to narrowing of
esophageal hiatus.
• Heartburn related to reflux of food.
• Pain related to spasm of the esophageal
muscle.
• Anxiety and stress related to disease.

27. Nursing interventions
• Before mealtime, provide for adequate rest
periods.
• Provide oral care before feeding. Clean and
insert dentures before each meal.
• Place suction equipment at the bedside, and
suction as needed.
• Maintain the patient in high-Fowler’s position
with the head flexed slightly forward during
meals.

28. Cont…
• Instruct the patient not to talk while eating.
Provide verbal cueing as needed.
• Encourage high-calorie diet that involves all
food groups, as appropriate. Avoid milk and
milk products.
• If oral intake is not possible or in inadequate,
initiate alternative feedings (e.g., nasogastric
feedings, gastrostomy feedings, or
hyperalimentation).

29. Cont…
• Keep patient in an upright position for 30 to
45 minutes after a meal.
• Observe for signs of aspiration
and pneumonia. Auscultate lung sounds after
feeding. Note new crackles or wheezing, and
note elevated temperature. Notify physician
as needed.
• Weigh patient weekly.