EPIDEMIOLOGY & DEMOGRAPHICS
• Annual incidence is about 1 in 100,000 persons.
• Although the onset of symptoms may occur at any age, it is more common in persons 30 to 50 yr old.
• Men and women are affected equally.
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Dysphagia to both solid and liquid
• Chest pain and vomiting of undigested food
• Symptoms of aspiration such as nocturnal cough; possible dyspnea and pneumonia
• If severe and prolonged, then possible weight loss
• Focal lung examination abnormalities and wheezing also possible
• Etiology is incompletely understood.
• This motility disorder is likely due to viral or autoimmune degeneration of the esophageal myenteric plexus.
• Herpes zoster and measles virus have been implicated.
• Association with the HLA class II antigen, DQw1, has been noted.
Achalasia is a motility disorder of the esophagus characterized by inadequate relaxation of the lower esophageal sphincter (LES) and ineffective peristalsis of esophageal smooth muscle. The result is functional obstruction of the esophagus. Achalasia is characterized by difficulty swallowing, regurgitation, and sometimes chest pain. Diagnosis is reached with esophageal manometry and barium swallow radiographic studies. Various treatments are available, although none cures the condition. Certain medications or Botox may be used in some cases, but more permanent relief is brought by esophageal dilatation and surgical cleaving of the muscle.
• Anorexia nervosa
• Gastric bezoar
• Peptic ulcer disease
• Esophageal disease:
Esophageal webs and rings
Diffuse esophageal spasm
Infiltrating gastric cancer
• Physical examination and laboratory analyses to rule out other causes and assess complications
• Imaging studies and manometry for diagnosis
• Assessment of nutritional status with albumin and prealbumin if indicated
• CBC, ECG, stress test, stool and emesis for occult blood if diagnosis is in doubt
Barium swallow with fluoroscopy may demonstrate the following findings:
• Uncoordinated or absent esophageal contractions
• An acutely tapered contrast column
• Dilation of the distal (smooth muscle portion) esophagus
• Esophageal air fluid level
Manometry may be indicated if barium swallow is inconclusive. Characteristic abnormalities are as follows:
• Low-amplitude disorganized contractions
• High intraesophageal resting pressure
• High LES pressure
• Inadequate LES relaxation after swallow
Three modalities of treatment:
Smooth muscle relaxants including nitrates and calcium channel blockers are effective in up to 70% of patients. Botulinum toxin injection will benefit up to 90% of patients but will require repeat injections.
• Mechanical dilation:
Fixed or pneumatic dilators may benefit up to 90%. Esophageal rupture or perforation is a rare complication that can be managed conservatively in some stable patients.
Open and thoracoscopic esophagomyotomy are available and effective (90%). This approach currently offers the most durable symptom relief. About 10% of patients undergoing surgery will have symptomatic reflux disease.
Prognosis is excellent in patients who respond to therapy. In long-standing disease or inadequately treated disease, there is an increased risk of squamous cell carcinoma. Chronic GERD, as a result of treatment, may be complicated by Barrett’s esophagus and malignant transformation.