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Surgery(achalasia cardia)
1. ACHALASIA CARDIA
Primary oesophageal motility disorder
Also called as cardiospasm –because of severe
spasm of circular muscles of lower end of
oesophagus.
The contracted segment doesn’t relax during
swallowing as a result there is dilatation of,
tortuosity and hypertrophy of the oesophagus
above
2. Aetiopathogenesis
Idiopathic- it occurs due to absence/degeneration of
Auerbach’s plexus throughout the body of oesophagus,
causing improper integration of parasympathetic impulse
Acquired variety- in America, caused by Trypanosoma
cruzi which destroys
plexus.(Chagas disease)
Stress
Emotional factors
Vitamin B1 deficiencies
ganglion cells of Auerbach’s
3. Pathophysiology
ACHALASIA CARDIA
Imbalance of nitric oxide and Ach
Neurotransmitter inhibition is decreased (nitric oxide)
Loss of inhibitory ganglionic cells in myentric plexus
Myenteric plexus inflammation/damage
4. Clinical features
Women around 20-40 yrs. of age are commonly
affected
Female:male::3:2
Progressive Dysphagia-which is more for liquids than
solid food.
Regurgitation and recurrent pneumonia are common
Malnutrition and ill health
Retrosternal discomfort - pain also radiates to
interscapular region
Odynophagia and weight loss
6. Investigations
Barium swallow-
• bird beak appearance of lower oesophagus,
• Dilatation of proximal oesophagus
• Absence of fundic gas bubble
• Sigmoid oesophagus
X-ray chest- retrocardiac air fluid level lateral view
Plain X-ray abdomen erect-fundic air bubble is absent
due to stasis of fluid in oesophagus
Oesophagoscopy-dilated sac containing stagnant
food and fluid due to stasis
LES is closed with air insufflation, rosette apperance
Oesophageal manometry- Aperistalsis in body of
oesophagus
Ultrasound- detects subepithelial tumor infiltration in
2ndy achalasia due to distal carcinama
8. Treatment
Heller’s cardiomyotomy- surgical 7-10cm long incision
made through lower oesophageal end and carried over to
stomach ,muscles are cut till mucosa bulges out.Myotomy
should be extended upto aortic arch and distally up to
stomach to 1-2cm below the junction
Forceful dilatation- using pneumatic balloon under
fluoroscopic control within LOS(300mmhg pressure applied
for 15 sec)
Injection treatment- inj botulinum toxin is injected in LES
endoscopically ,blocks Ach release
Drugs- sublingual nifedipine gives short term releif
Endoscopic myotomy