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Monday, October 11, 2010

Understanding Achalasia, the "impossible-eating" disorder!

Achalasia is a disorder of the esophagus in which the lower sphincter is not fully loosened, remaining contracted and not allowing foods to go in the stomach. From Ancient Greek  (a-, “not”) +  (khalasis, “relaxation”) < (khala, “I loosen”). This disease is also called:
Achalasia cardiae, Cardiospasm, Esophageal achalasia and Esophageal aperistalsis.
This condition of the Lower Esophageal Sphincter (LES) is also associated with a difficult creation of peristaltic waves, so that the passage of food through esophagus is made more difficult and impossible.
The causes of Achalasia are generally unknown, except for the American form, caused by Trypanosoma crusi (Chagas Disease). It is thought that also may exist a viral form, but for now everything remains only a hypothesis.
Anatomically, it seems that at the site of LES, there co-exists a Muscular and a Neuronal damage. The neurons that are damaged are commonly “NO-secreting” neurones, and the muscular lining of the esophagus seems thicker than normal.

esophageal achalasia
Blocked Lower Esophageal Sphincter

Signs and symptoms of Achalasia
-Dysphagia (difficulty in swallowing): this symptom is present in almost 100% of patients with achalasia. It is felt as a weighting mass inside the chest. In case of achalasia this symptom comes slowly day by day, and not as in Esophageal cancer, in which the weighting mass in the chest is severe from the beginning.
-Vomiting: it is common in a patient with achalasia the need to vomit, and after vomiting, the feeling of an empty and relaxed esophagus. In achalasia, the food that comes from the mouth is not acid, like in the case of Gerd (The acid reflux disease), because it hasn;t reached the stomach yet.
-Polmonitis ab-ingestis: passing of food from esophagus to trachea, and risk of infections!
-Weight loss: at the advanced stages, there is weight loss that comes as a result of bad nutrition.
Treatment of Achalasia:
Every kind of treatment for this disease is not totally healing. All of the treatments are used to relieve the symptoms of the disease, so that the person doesn’t lose the quality of life, and also to prevent the complications, that can come from prolonged Achalasia.
The pharmacological treatment is:
Calcium channel blockers (Nifedipine in this case)
Nitrates (Isosorbide Dinitrate)
Botulinum Toxin (Botox), but this is a temoporary effect and needs to be redone.
The interventions are:
-Balloon dilation: in which the muscle fibers are stretched and slightly torn by forceful inflation of a balloon placed inside the lower esophageal sphincter. Physicians who specialize in Achalasia and have performed many of these forceful balloon dilatations achieve better results and fewer perforations.
-Heller myotomy: It can usually be performed by a keyhole approach, or with laparoscopy. The myotomy is a cut along the esophagus, starting above the LES and extending down onto the stomach a little way. The esophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner muscosal layer intact.
-Dor or Toupet partial fundoplication: Surgery that is added to Myotomy, just to prevent the acid reflux. The gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus but not circling all of the esophagus like in Nissen’s fundoplication. Then it is stitched in place, reinforcing the closing function of the lower esophageal sphincter.

Generally, Achalasia is NOT a mortal situation, and a patient can live all of his life with this condition. But, the quality of life is reduced, because of the continuing difficulty when eating and drinking. Although there is no final treatment that totally cures the disease, it should be treated with the symptomatic types of treatments available. The mos dangerous complication is Polmonitis ab-ingestis, that is an inflammation of the lungs deriving from food passed from the esophagus. It should be treated with antibiotics, and if the part of swallowed food is still in the lung, it should be removed chirurgically!

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