Up ] Abdominal incisions ] Groin hernias ] Other hernias ] Peritonitis ] Appendicitis ] Ovarian cysts ] Oesophageal perforation ] Perforated peptic ulcer ] Diverticular disease ] Upper GI haemorrhage ] Lower GI haemorrhage ] Small bowel obstruction ] Large bowel obstruction ] Sigmoid and caecal volvulus ] Pseudo-obstruction ] Enterocutaneous fistulae ] Mesenteric ischaemia ] Acute pancreatitis ] Pyogenic liver abscess ] Amoebic liver abscess ] Hydatid disease ] Gynecological pain ] GORD ] [ Achalasia ] Oesophageal carcinoma ] Peptic ulcer disease ] Gastric carcinoma ] Hepatocellular carcinoma ] Pancreatic cancer ] Chronic pancreatitis ] Colonic polyps ] Colorectal carcinoma ] Liver metastases ] Anal carcinoma ] Inflammatory bowel disease ] Anal fissure ] Haemorrhoids ] Perianal sepsis ] Pilonidal sinus ] Rectal prolapse ] Jaundice ] Gall stones ] Portal hypertension ] Ascites ] Stomas ] Abdominal pain ] Abdominal masses ]

Dysphagia and achalasia

Causes of dysphagia

  • Extrinsic mechanical
    • Carcinoma of the bronchus
    • Thoracic aortic aneurysm
    • Goitre
  • Intrinsic mechanical
    • Benign stricture
    • Oesophageal carcinoma
    • Bolus obstruction
  • Primary neuromuscular
    • Achalasia
    • Diffuse oesophageal spasm
    • Nutcracker oesophagus
  • Secondary neuromuscular
    • Multiple sclerosis
    • Systemic sclerosis
    • Chagas' disease
    • Autonomic neuropathy

Investigation of dysphagia

  • History and examination may suggest underlying pathology
  • Consider the following investigation
    • Upper GI endoscopy
    • Barium swallow
    • Endoscopic ultrasound
    • Oesophageal manometry
    • CT or MRI scan

Achalasia

  • Due to reduced number of ganglion cells in myenteric plexus
  • Vagi show axonal degeneration of the dorsal motor nucleus and nucleus ambiguous
  • Aetiology is unknown but a neurotropic virus may be important
  • Similar to Chagas' disease due to Trypanosoma Cruzi

Clinical features

  • Commonest in patients between 40 - 70 years
  • Male : female ratio is approximately equal
  • Symptoms include dysphagia, weight loss, regurgitation, chest pain
  • 5% of patients develop squamous carcinoma

Investigations

  • CXR - widening of mediastinum, air / fluid level and absence of gastric fundus gas bubble
  • Barium Swallow - dilatation & residue, small tertiary contractions and 'rat tail' of distal oesophagus

Barium swallow showing achalasia

  • Manometry - absent primary peristaltic wave and non-propulsive tertiary contractions
  • Endoscopy - essential to exclude 'pseudoachalasia' due to submucosal carcinoma

  • Tight lower oesophageal sphincter which relaxes with gentle pressure usually seen
  • Isotope transit studies

Differential diagnosis

  • Diffuse oesophageal spasm
  • Infiltrating carcinoma
  • Hypertrophic lower oesophageal sphincter
  • Scleroderma
  • Chagas' disease

Treatment options

Balloon Dilatation

  • Rider Moeller Balloon
  • Inflated to 300 mmHg for 3 minutes
  • 3% perforation rate
  • 60% dysphagia free at 5 years
  • May be repeated if necessary

Cardiomyotomy

  • Described by Heller (1914) & Grenveldt (1918)
  • May be performed laparoscopically
  • 85% will have an improvement in symptoms
  • 10% develop oesophageal reflux
  • 3% will develop and oesophageal stricture
  • Some combine cardiomyotomy with an antireflux operation

Bibliography

Banerjee S. Achalasia of the cardia. Hospital Update  Sep 1993. 480 - 488.

Hunt D R, Wills V L. Laparoscopic Heller Myotomy for achalasia.  Aust NZ J Surg 2000;  70:  582-586.

Hunter J G, Richardson W S. Surgical management of achalasia.  Surg Clin N Am 1997; 77: 993-1115.

Leslie P,  Carding P N,  Wilson J A.  Investigation and management of chronic dysphagia.  Br Med J 2003;  326:  433-436.

Navaratnam R M,  Clayman C,  Winslet M C.  Clinical advances in the evaluation of oesophageal disease.  Hosp Med 2000;  64:  194-199

 

 
 

Copyright 1997- 2013 Surgical-tutor.org.uk