Achalasia

Achalasia is a condition which affects approximately 1 in 50,000 people. In this condition the ability of the oesophagus to propel food from the mouth to the stomach is lost and the valve mechanism (sphincter) at the lower end of the oesophagus fails to relax to allow the food bolus into the stomach.

Symptoms

Patients suffering from achalasia may notice progressive difficulty in the ability to swallow food, the time taken to eat a meal increases, the patient may need to drink a lot of liquid in order to "help the food down" and sometimes on swallowing there may be quite severe pain in the central chest and back. After a time weight loss is noted.

Diagnosis

This is made by use of an x-ray (barium swallow), oesophageal manometry (a test to measure the pressure in the sphincter muscle) and endoscopy, the latter to exclude other causes of food blockage.

Treatment

1. Pharmacological therapy
Calcium channel blockers and nitrates may decrease the high pressure in the lower oesophageal sphincter. These medicines are effective in less than 10% of patients and are used principally in elderly patients in whom other forms of treatment may be risky.

2. Injection of Botulinum toxin into the lower oesophageal sphincter.
This drug blocks the release of a nerve transmitter, acetylcholine, promoting the sphincter to relax. Long term results of this have been disappointing and patients may develop antibodies to botulinum.

3. Pneumatic balloon dilatation.
A balloon is placed into the low oesophagus and inflated to a defined pressure. This can "split" the fibres of the low oesophageal sphincter. This treatment is successful in approximately 70% of patients but at least 50% require a further balloon dilatation.

The risk of this treatment is inadvertent perforation of the oesophagus (approximately 5-7%). This complication requires urgent surgery to repair the perforation.

4. Surgical operation - Heller's cardiomyotomy

This can now be done by keyhole surgery with usually a 1-2 night stay in hospital. In this operation the muscle of the lower oesophageal sphincter is divided under direct surgical vision. The operation is successful in approximately 85-90% of patients. A few patients have "resistant" achalasia which may require a further cardiomyotomy or, in very severe cases, removal of the oesophagus (oesophagectomy).

Outcome of surgery >>