Achalasia Cardia

Presentation

• Reflux
• Regurgitation of food that is undigested
• Chest pain (atypical finding)
• Progressive dysphagia to not just solids but also liquids
• Aspiration/aspiration pneumonia
• Weight loss

Diagnosis

The diagnosis of this rare disorder is usually suspected in a person with dysphagia to both liquids and solids with associated regurgitation of food that is undigested. The diagnostic modalities often employed in achalasia.

• Endoscopy – Most people with dysphagia need esophagogastroduodenoscopy (EGD) to rule out mechanical obstructions due to cancer.
• Barium Esophagogram – Esophageal dilation with gradual tapering, giving a “bird’s beak” appearance is the classic description of achalasia on barium esophagram.
• Esophageal Manometry – The gold standard for diagnosis of achalasia, it assesses the esophageal pressure along the length of a catheter placed into the oesophagus. High-resolution manometry can show pressure data as topography plots.
• Endoluminal Functional Lumen Imaging Probe (EndoFLIP) – EndoFLIP, based on the principle of impedence planimetry, allows real-time measurement of gastroesophageal junction(GEJ) distensibility.

Achalasia Cardia Treatment Modalities in Kolkata

It can be managed but not cured. There are 5 major treatment modalities

• Pharmacotherapy – Considered the least-effective treatment option, the clinical response to these agents is short-lived and their side effects are unfavourable. The two most commonly used medications include long-acting nitrates and calcium channel blockers.
• Botox Injections – It is a useful treatment strategy for those who cannot tolerate invasive therapies, such as surgical myotomy or pneumatic dilatation. This technique involves pushing a maximum of 100 units of toxin using a sclero-needle close to the squamo–columnar junction. The response rate in the first month is as high as 80%–90%; however, the effect wanes over time so that approximately 50% of the patients are symptomatic at the end of first year. Thus, recurrent treatments are usually required.
• Pneumatic Dilation
  • Most effective non-operative treatment with a success rate of 55-70 percent for single dilation
  • Stretches and ruptures your LES muscle fibers
  • Most people need more than one dilation
  • Adverse / Side Effects – Perforation rate ~1% (0.67 – 5.6%) – overall complication rate 11% (Perforation, GERD, intramural hematoma)
• Surgical – Surgical myotomy is a technique that involves the division of the LES circular muscle fibres. Today, Laparoscopic Heller Myotomy (LHM) has become the standard Achalasia Cardia surgery approach in Kolkata because of improved morbidity and quicker recovery time.

Esophagectomy – “End-stage” achalasia, characterized by a dilated and tortuous esophagus (megaesophagus or sigmoid esophagus), is often unresponsive to conventional treatments for achalasia. Although PD is ineffective, surgical myotomy should still be considered the initial treatment before consideration of the more morbid esophagectomy.

Advances in treatment for achalasia

Peroral endoscopic myotomy: Peroral endoscopic myotomy or POEM, a novel endoscopic procedure, uses the oral cavity as an orifice entry point to perform myotomy of the LES. After inserting an endoscope down the esophagus toward the esophageal gastric junction, a surgeon performs the myotomy by cutting only the inner, circular LES muscles through a submucosal tunnel created in the proximal esophageal mucosa.

POEM differs from laparoscopic surgery, which involves complete division of both circular and longitudinal LES muscle layers. The dysfunctional muscle fibers that prevent the LES from opening are cut in order to allow food to enter the stomach more easily.