ACHALASIA CARDIA

PRESENTED BY
DR. MUHAMMAD IMRAN
THORACIC SURGEON
 DEFINITION
 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
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 ganglion cells of Auerbach’s plexus.(Chagas disease)
 Stress
 Emotional factors
 Vitamin B1 deficiencies
Pathophysiology
Myenteric plexus inflammation/damage

Loss of inhibitory ganglionic cells in myentric plexus

Neurotransmitter inhibition is decreased (nitric oxide)

Imbalance of nitric oxide and Ach

ACHALASIA CARDIA
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
 Dysphagia
Triad of Achalasia cardia

Regurgitation Weight loss

Staging
I.Proximal dilatation <4cm
II.Dilatation b/w 4-7 cm
III.Dilatation >7cm
 BARIUM SWALLOW
• Barium swallow is an excellent tool in the
diagnosis of achalasia
S
• Classic appearance shows a dilated
V esophagus which tapers to a classic “bird’s
beak” appearance
M
• The diagnostic accuracy of a barium
C swallow was 95% in one study
MANOMETRY
• Elevated resting LES
pressure (often above 45
mmHg)
S• Incomplete LES relaxation
• The LES should drop to <8
V mmHg
• achalasia LES relaxation in
M
response to a swallow may
be incomplete or absent
C
UPPER GI ENDOSCOPY

• All patients with suspected achalasia should

undergo endoscopy to rule out malignancy
S • On entering the esophagus, it is usually
large and will potentially have retained
food
M
• While the LES does not open
spontaneously, it can be passed with gentle
C pressure
 Upper GI Endoscopy

C
 DIAGNOSIS IN ACHALASIA
• Additional modalities such as CT scan or
S endoscopic ultrasound (EUS) can be
helpful in the workup of a patient for
V
achalasia if another cause is suspected
(such as malignancy)
M

C
MEDICAL TREATMENT
• Medical therapy with calcium channel
blockers or nitrates
• They are taken 10-30 minutes before meals
S
• While they have been shown to have
V moderate success, they require the patient
to take them perpetually
M • They are not recommended as first-line
therapy
C
BOTOX
• Botulinum neuortoxin type A
• Inhibits the release of acetylcholine
S
• The idea for the use of BOTOX came from an
understanding of the pathophysiology of
V achlasia
• By blocking the release of Ach from the
M presynaptic channels in the ganglia of
Auerbach’s plexus, the theory is that the balance
C
of neurotransmitters is restored
 BOTOX

S
PNEUMATIC DILATATION
• Considered the most effective nonsurgical
treatment of achalasia
• Involves passing the pneumatic device to
S
the LES, using both endoscopy and
V
fluoroscopy to properly place the balloon
• The balloon is inflated to a pressure
M between 7 to 15 psi
• Patients are usually observed for six hours
C
and then discharged home
 Pneumatic dilatation

S
 Heller’s Myotomy
• First described by Ernest Heller in 1913 where he
used an abdominal approach to perform an anterior
S
and posterior esophagomyotomy
• Surgical therapy now involves usually performing
V
only an anterior myotomy, via either abdominal or
M
thoracic approach
• In addition to laparoscopic myotomy, thoracoscopic
C myotomy has also been described
 To fundoplicate, or not to
• 30% of pts complained of significant heartburn
• 24 hr pH probe or endoscopy demonstrated that
S
• 60% of pts had significant reflux
• “Objective analysis reveals an unacceptable rate
V of gastroesophageal reflux in laparoscopic
Heller’s myotomy without an antireflux
procedure. We therefore recommend
M
performing a concurrent antireflux procedure.”
C
 Dor vs Toupet fundoplication
• Dor fundoplication is an anterior 180
degree wrap
S

V • Toupet fundoplication is a posterior

270 degree wrap
M

C
Dor fundoplication
Toupet fundoplication
 Achalasic sigmoid esophagus
● Markedly dilated
esophagus with
tortuous, angulated
S
shape
● Previously believed
that this would require
esophagectomy or at
the very least preclude
fundoplication.
 A new approach to achalasia
● Submucosal endoscopic esophageal
S
myotomy: a novel experimental
V approach for the treatment of achalasia
M

C
A new approach to achalasia
POEM
 SUMMARY
● Achalasia is a process that affect the
myenteric plexus of the esophagus leading
S to high resting LES pressures and
esophageal aperistalsis
V ● Medical therapy is ineffective
● BOTOX should be reserved for patients
M
who are not able to undergo other
C
interventions
● Pneumatic dilation is effective, but has the
risk of perforation
 SUMMARY
• Laparoscopic Heller’s myotomy has excellent
results
S
• Should be accompanied by either Dor or Toupet
V fundoplication (not a Nissen)
• The myotomy should be at least 5 cm on the
M esophagus to 2 cm on the stomach, and possibly
longer
C • The robot may have a role in the future