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Achalasia: Diagnosis and Treatment

How is achalasia diagnosed?

Three tests are most commonly used to diagnose and evaluate a swallowing problem:

  • Barium swallow. The patient swallows a barium preparation (liquid or other form) and its movement through the esophagus is evaluated using X-ray.
  • Endoscopy. A flexible, narrow tube called an endoscope is passed into the esophagus and projects images of the inside of the esophagus onto a screen.
  • Manometry. This test measures the timing and strength of esophageal (pump) contractions and lower esophageal sphincter (valve) relaxation.

How is achalasia treated?

If left untreated, achalasia can be debilitating. People with the condition experience considerable weight loss that can result in malnutrition. Lung infections and pneumonia due to aspiration of food can result, particularly in the elderly.

There are several successful treatments available for achalasia, including:

  • Surgery -- The traditional surgical approach since the early 20th century to treat achalasia has been the Heller myotomy. In this operation, the muscles of the valve between the esophagus into the stomach are cut. Traditionally, the Heller myotomy is completed through an open incision in the abdomen or through an incision in the left side of the chest between the ribs. These types of incisions often required hospitalization of up to a week for adequate recovery.

Today, achalasia can be treated successfully by laparoscopy. Using five small incisions, a Heller myotomy can be accomplished (called laparoscopic Heller myotomy). It has been shown that the addition of a partial fundoplication (Dor) minimizes reflux and protects the esophagus from damaging gastroesophageal reflux. This operation usually requires one day of hospital stay and recovery is typically accelerated when compared to conventional surgery.

  • Balloon dilation - Occasionally, achalasia can be treated non-surgically with balloon (pneumatic) dilation. While the patient is under light sedation, the gastroenterologist inserts a specially designed balloon through the lower esophageal sphincter and inflates it. The balloon disrupts the esophageal muscle. Some patients may have to undergo repeated dilation treatments in order to achieve symptom improvement, and the treatment may have to be repeated every few years to ensure long-term results. On average, this procedure offers a 75 percent chance of relieving symptoms for a period of years. A major problem associated with the procedure, however, is potential perforation of the esophagus.
  • Medication -- Patients who are not appropriate candidates for balloon dilation or surgery may benefit from Botox (botulinum toxin) injections. Botox is a protein made by the bacteria that cause botulism. When injected into muscles in very small quantities, Botox can relax spastic muscles. It works by preventing nerves from sending signals to the muscles that tell them to contract. A smaller percentage of patients (up to 35 percent) achieve good short-term results using Botox compared to balloon dilation. In addition, the injections must be repeated frequently in order to achieve symptom relief.Other medications, such as nifedipine and nitroglycerin, may help to relax spastic esophageal muscles. Patients who take nifedipine every day may experience satisfactory results for a couple of years.

Your health care team will discuss the possible risks and benefits of each treatment option with you.

It must be remembered that treatment of achalasia does not fix the esophagus, it only attempts to improve esophageal emptying. This, however, is at the risk of allowing the stomach to empty it contents into the esophagus (reflux).

Regardless of the therapy, long-term follow up is necessary to assure that the esophagus can be preserved as a passive conduit. This requires adequate esophageal emptying after the treatment of choice and prevention of gastroesophageal reflux. The obstructed esophagus or one that is subjected to reflux will dilate and expand and may eventually need to be replaced.

Since the underlying cause for achalasia is unknown, it is not possible to restore the function of the esophagus. Most patients will have some residual symptoms after successful treatment but should be able to eat almost normally.

References:

The Society for Thoracic Surgeons. "Achalasia." (2006) www.sts.org/doc/4120 Rice TW, McKelvey AA, Richter JE, Baker ME, Vaezi MF, Feng J, Murthy SC, Mason DP, Blackstone EH. A physiologic clinical study of achalasia: should Dor fundoplication be added to Heller myotomy? J Thorac Cardiovasc Surg, 2005 Dec;130(6):1593-600. Pasricha PJ. "Achalasia." www.uptodate.com/


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