What is Achalasia?

Achalasia is a swallowing condition that affects the gullet (oesophagus). A the lower end of the oesophagus, there is a muscle know as the lower oesophageal sphincter. This muscle controls the passage of food from the gullet into the stomach. Then this muscle relaxes, food can move from the gullet into the stomach. In achalasia, this muscle does not relax adequately preventing passage of food from the gullet into the stomach. Over time a large amount of food and fluid can collect in the gullet causing it to remain dilated and baggy. 

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What causes achalasia?

In achalasia the nerve cells that affect the lower oesophageal sphincter or the lower oesophagus muscle do not function. The cause of this is unknown but significant interferes with normal swallowing. In some cases it is thought to be related to a viral infection or an autoimmune condition.

What are the symptoms of achalasia?

The most common symptoms of achalasia include:

  • Difficulty swallowing- both liquids and solids
  • Regurgitation of food
  • Chest pain/heartburn
  • Unexplained weight loss
  • Sensation of globus or a lump at the back of the throat

How is achalasia diagnosed?

A series of investigations may be performed prior to diagnosing achalasia. These include:

    • Chest x-ray performed for chest pain may note a wide gullet
    • Barium swallow is a common test performed for a achalasia where individuals are asked to swallow a thick liquid dye called barium after which a series of x-rays are performed. The barium “lights up” on the x-rays and demonstrates the outline of a widened gullet/oesophagus in achalasia. It will also show a tight muscle at the lower end of the oesophagus where the tight sphincter is situated. 
    • Oesophageal manometry or motility studies assess the change in pressures in the gullet caused by contraction of its muscle. A thin tube is passed through the nose into the oesophagus and pressure sensors detect the changes in pressure. In achalasia three abnormalities are usually picked up; high pressure at the lower oesophageal muscle, lack of relaxation of this muscle and lack of contractions of the oesophageal muscle to encourage passage of food. 
    • Endoscopy helps to visualise the inside of the gullet and can rule out other causes of the afore mentioned symptoms. In achalasia the oesophagus will appear dilated with retained food and some evidence of inflammation. 

What are the consequences of not undergoing treatment?

Without any form of treatment, achalasia with result in progression of the symptoms mentioned above. In the long term, achalasia has been show to have a increased risk in developing cancer of the oesophagus due to prolonged period of inflammation.

What are the treatment options?

Achalasia can be managed with surgical or non-surgical options

    • Medications including nifedipine or nitrates can be tried which help to relax the lower oesophageal sphincter. The effects of these are short lasting however but can be used as a temporary solution. The can cause headaches as a side effect to the medication. 
    • Balloon dilation can be attempted. This is performed under local or general anaesthetic where an endoscopy is performed and a balloon is inflated in the region of the tight sphincter to dilated it. This tends to help with swallowing but may need to be performed a few times. Perforation or a hole in the oesophagus is a major complication from the procedure. 
    • Injection of botox can be injected into the muscle. This helps to relax the muscle and can be performed during endoscopy. 
    • Surgical options wise a procedure called a Heller’s Myotomy can be performed.

How is a Heller’s Myotomy performed?

Heller’s Myotomy is a key hole or laparoscopic procedure performed under general anaesthetic. Smaller, multiple cuts, usually 4 are made on the abdomen and air is inflated to created space in the abdomen. An instrument with a small camera is then inserted into the abdomen. This camera is then used to direct other instruments in the abdomen to cut the ring of muscle (sphincter) at the lower aspect of the oesophagus. 

 

At the same time a second procedure (fundoplication) tends to be performed to prevent acid reflux which is a known side effect of a Heller’s Myotomy. 

What are the risks surgery?

  • Infection
  • Pain
  • Intraoperative or postoperative bleeding
  • Collection of fluid or blood in the wound (seroma or haematoma)
  • Persistence of symptoms and need for further surgery/procedure
  • Oesophageal perforation
  • Need for conversion to open surgery
  • Complications related to the fundoplication including difficulty swallowing, bloating and belching
  • Scarring in the abdomen also known as adhesions
  • Complications related to a prolonged operation/anaesthetic including clots in the legs, lungs, brain or heart.

How long will I be in hospital and what is the recovery period and follow up?

After surgery the course of recovery is as follows:

  • Tend to stay in hospital for 2-3 days following surgery
  • The first day the nasogastric tube remains in situ and only sips of water are recommended
  • Following day 1 the diet is slowly built to other liquids and a soft diet on discharge
  • A soft diet is to be continued for 4 weeks following surgery to allow for adequate healing. A antacid during this period is also recommended
  • 2- 3 weeks before going back to work
  • No heavy lifting or strenuous activity for 6 weeks
  • Patients will be followed up 4-6 weeks after surgery

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