Oesophageal Achalasia

Oesophageal achalasia is a motility disorder of the oesophagus as a result of disturbed peristalsis and incomplete relaxation of the LES manifested by difficulty in swallowing, regurgitation, and chest pain (O’Neill, Johnston, & Coleman 2013). In this regard, diagnostic evaluation is of great value as it is a challenge for clinicians to diagnose achalasia due to clinical manifestations being equivocal of the disease which can be attributed to other diseases, such as GERD or scleroderma (O’Neill, et al, 2013). Patients presenting with achalasia will all have a complete history taken to aid in the diagnosis (Constantini, et al, 1993) and according to Professor J. Windsor (personal communication, April 20, 2017), “it can usually take a period of months assessing progressive swallowing difficulties before a definitive diagnosis can be made. Specific blood tests are not required post interpretation of symptoms but an albumin test may be performed on malnourished patients.” According to Professor J. Windsor (personal communication, April 20, 2017), prior to any treatment, the patient with achalasia will undergo routine blood tests which are not necessarily related to the disease process. The tests are in addition to the diagnostic examinations and preoperative assessments required. Symptom Evaluation According to Allaix, Ramirez, & Patti (2016), dysphagia is the hallmark symptom reported by around 95% of achalasia clients with presentations of difficulty swallowing both solids and liquids and is usually accompanied by loss of weight. Regurgitation both in prone and supine position is the second most common symptom presented by 60-70% of achalasia patients. If aspiration develops, coughing, wheezing and pneumonia episode arises (Allaix, et al, 2016). Allaix, et al (2016) survey demonstrated that 40% of predominantly younger patients present with heartburn due to undigested foods in the distal oesophagus which often confuses achalasia as GERD. The cause of chest pain is unknown and can delay timely and accurate diagnosis of achalasia as it masks other symptoms like dysphagia and regurgitation (Eckardt, Stauf, & Bernhard, 1999). Often achalasia chest pain can be mistaken for angina-like retrospinal pain which occurs in approximately 50% of achalasia patients (Allaix, et al, 2016). According to Allaix, et al (2016), the Eckardt score is frequently used in the diagnosis of achalasia. The scoring system for dysphagia, regurgitation, and chest pain is as follows: 0 – indicates absence of symptoms, 1- suggests occasional symptoms, 2- shows daily occurrence of symptoms, and 3- illustrates symptoms which occur during meals. With regards to loss of weight, 0- indicates no weight loss, 1- marks a loss of less than 5kg, 2- implies 5-10kg loss, and 3- indicates 10kg and more of lost weight. 12 is the maximum score on the system. Diagnostic Evaluation Aside from the symptomatic assessment, a comprehensive interpretation is made to establish a diagnosis (Vaezi, et al, 2013). The usual tests ordered are: • Endoscopy • Oesophagogastroduodenoscopy (OGD) • Barium Swallow • Oesophageal Manometry Endoscopy Upper endoscopy is usually the first …show more content…
The appearance of narrowed gastroesophageal junction, the slow emptying of barium and absence of peristalsis are characteristics of achalasia (Allaix, et al, 2016).
The barium swallow defines the shape of the oesophagus and lower oesophageal sphincter (LES) and may also show increased peristalsis and spasm trying to overcome the LES that does not relax. This condition is called vigorous achalasia (Fisichella, Raz, Palazzo, Niponmick, Patti, 2008).
Oliveira, et al (1997) reported that in some cases, the barium oesophagram may not present anomalies especially in the early stages of the disorder. A radiologist’s objective interpretation will help establish a diagnosis. Otherwise, patients will be subjected to a further approach, such as the Timed Barium Esophagram (TBE) which involves ingesting a large quantity of barium and eventually, give objective evaluations to patients with achalasia post treatment.
Oesophageal …show more content…
Classic achalasia
2. Achalasia with compression effects
3. Spastic achalasia
This classification helps in treatment decisions, with Type 2 achalasia being the most responsive to Pneumatic Dilatation, Hellers Myotomy and Botox Injection, thereby having best outcomes in the palliative treatment of the achalasia (O’Neill, et al, 2013).
According to Alonso, Gonzalez-Conde, Macenlle, Pita, Vazquez-Iglesias (1999), the increasing use of the traditional and HR manometry, before and after treatments for achalasia, assesses the success of these interventions, while benchmarks for successful outcomes still have not been precise. Therefore, the success of manometry in general should be accompanied by a symptomatic interpretation of the favourable therapeutic treatment of