Achalasia - Epidemiology | Cheat Sheet

University:
Western Sydney University
Course:
MEDI 2003 | Clinical Sciences 2
Academic year:

2024
Views:

300

Pages:

6
Author:

Mariam A. A.

Achalasia Epidemiology Most common age of diagnosis is between 25 and 60. Both genders equally affected Causes Unknown Most common Viral or parasitic infections Autoimmune Primary Secondary Unknown Cancers e.g. gastric or lymphomas Genetic or autoimmune Older adults -> more than 60 Younger than 50 Rapid onset of symptoms Bird’s peak on imaging Significant weight loss Gradual onset Imaging shows irregular narrowing, modules, shouldering or distinct mass Pathophysiology Caused by degeneration of the myenteric nerve plexuses. Hallmark -> failure of the LES to relax during swallowing and absent peristalsis in oesophageal body Types Type Description Classic achalasia I Oesophageal muscles barely contract Most common II Pressure builds in oesophagus -> compression More severe symptoms than I Spastic achalasia Most severe III Abnormal contractions at the distal end where the oesophagus meets the stomach Contractions -> pain that can awaken from sleep Pain may also mimic a heart attack Clinical Features Non-specific Dysphagia Most common Regurgitation Chest pain or discomfort Coughing esp. at night Chocking Weight loss Investigations Triple testing as no test is definitive Barium swallow First line Distal part -> bird beak like narrowing Dilation of the part above Endoscopy Classical findings -> dilated oesophagus with pooled saliva or food residue Excluded malignancy/pseudoclassic Oesophageal manometry Most sensitive and gold standard Absent peristalsis at LES that fails to relax during swallowing High LES pressure Decreased motility at mid oesophagus Can detect location and severity Allows for sub classification -> influences management pH monitoring to rule out GERD Management Aims Reduce pressure at LES -> improves food passage Myotomy -> laparoscopic or preoral endoscopic (POEM) Preoral is associated with a higher rate of post-procedural rate of GERD Can be managed with acid suppression medications Definitive and gold standard Complications: mucosal tearing, reflux, bleeding, damage to lungs, spleen, stomach, oesophagus or liver Pneumatic balloon dilatation Less invasive than myotomy More common approach? Balloon inflation near LES Decreases oesophageal pressure and stretches muscles until they relax enough to allow for food passage Most patients note improvement Improvement may be only temporary Complications: perforation, reflux (most common), chest pain (usually resolves within days, bleeding (rare) Botulinum toxin type A Injected into four quadrants of the LES Improves symptoms Needs to be repeated at intervals of 3 to 12 months As effect is limited and lasts for up to a year 70% Used when other therapies are not suitable or poor surgical candidates or elderly patients Complications: mucosal injury, bleeding, nonfetal mediastinitis, pneumothorax Pharmacological Nitrates, CCBs Limited benefits Used for poor surgery patients Associated with significant gastrointestinal and cardiovascular effects E.g. hypotension May need speech pathologist intervention Dietary changes are not helpful DDx Pseudo achalasia Rare Symptoms mimic achalasia but have other causes -> e.g. oesophageal cancer Complications Oesophageal squamous carcinoma Due to ongoing inflammation secondary to food retention Aspiration pneumonia Most common