Achalasia Cardia

Achalasia cardia is a condition wherein the lower oesophageal sphincter fails to relax.

1. Achalasia Cardia synonym : Cardiospasm Lavina Belayutham

2. Definition 1.‘Achalasia’ is a Greek term that means "does not relax’. 2 . It is a primary oesophageal motility disorder associated with the spasm of the lower oesophageal sphincter due to neuromuscular incoordination characterised by: a) spasm of the cardiac end of the oesophagus b ) dilatation of the lower two thirds of the oesophagus

3. Etiology Hurst : Degeneration of the Auerback’s plexus leading to failure of relaxation of the cardiac orifice. Jackson : Abnormal pinch-cock action by the right crus of the diaphragm. - Aerophagia may be one cause of the dilated oesophagus. -Principal lesion is the denervation of the oesophageal smooth muscles. - Trypanosoma cruzi of the myenteric plexus may be associated with megaoesophagus ( Chaga’s disease)

4. Symptoms Affects both male and female Insidious in onset Retrosternal or epigastric fullness following meals is the main symptom Dysphagia is a late symptom( more to liquids than solids) Regurgitation of swallowed food (especially at night ) Loss of weight

5. Signs - Pooling of saliva may be seen on indirect laryngoscopy and may be associated with reflux laryngitis.

6. Diagnosis Radiography (barium swallow) Fusiform dilatation of the oesophagus with fluid level ‘Pencil-tip’ or ‘bird’s beak’ smooth filling defect of the cardiac end of oesophagus Hurst phenomenon : Barium gets into the stomach like snow flakes. Loss of fundal gas shadow.

7. 2. Manometric studies - low pressure at the body of the oesophagus and high pressure at the lower sphincter with failure of the sphincter to relax 3. Endoscopy - To exclude benign strictures or development of carcinoma

8. Treatment 1.Medical : - Smooth muscle relaxants like isosorbide dinitrite,and calcium channel blockers like diltiazem,nifedipine and verapamil have been tried.

9. 2.Surgical: -Modified Heller’s operation ( myotomy of the narrowed lower portion of the oesophagus ) -Balloon dilatation or dilatation with hydrostatic bag or ‘Hurst-mercury’ boogies/ - Botulinum toxin type A injection (to relax the lower oesophageal sphincter) - Anastomosis between the stomach and oesophagus may be necessary if the oesophagus is grossly lengthened or kinked.