Achalasia

Question 1

What is the purpose of the oesophagus?

Answer 1

Connects the pharynx (level of C6) to the stomach (level of T11)

Question 2

Where is the oesophagus located?

Answer 2

Between trachea and spine

Question 3

Through which hiatus does it cross the diaphragm and which level?

Answer 3

Oesophageal hiatus at the level of T10

Question 4

Which part is extraperitoneal and which is intraperitoneal?

Answer 4

Thoracic oesophagus is extraperitoneal
Abdominal oesophagus is intraperitoneal

Question 5

What are the 4 oesophageal constrictions?

Answer 5

Cricopharyngeal sphincter at C6
Crossing of aortic arch at T4/5
Crossing of left main bronhchus at T5/6
Crossing of diaphragm at T10

Question 6

What is the function of the oesophagus?

Answer 6

Passage of food and liquids between oropharynx and stomach

Question 7

What is the cervical vasculature the of the oesophagus?

Answer 7

Oesophageal branches of inferior thyroid artery and inferior thyroid vein

Question 8

What is the thoracic vasculature the of the oesophagus?

Answer 8

Oesophageal branch’s if the thoracic aorta
Azygos and heniazygos veins

Question 9

What is the abdominal vasculature the of the oesophagus?

Answer 9

Oesophageal branches of the left gastric arteries
Left gastric vein (which drains into the portal circulation)

Question 10

Which lymphatic system drains the oesophagus?

Answer 10

Mediastinal lymph nodes

Question 11

Which nerves innervate the oesophagus?

Answer 11

Sensation - vagus nerve
Sympathetic - cervical and thoracic trunk (decrease peristalsis and glandular activity and transmit pain)
Parasympathetic - striated muscle - vagus nerve.
Smooth muscle - parasympathetic fibres of vagus nerve

Question 12

What are the 4 layers of the oesophagus?

Answer 12

Mucosal (innermost) - non keratinising stratified squamous epithelium. Transitions to columnar epithelium at GE junction.
Submucosal -contains blood vessels, glandular epithelium and meissner’s plexus
Muscular -contains inner circular and outer longitudinal muscle fibres. Auerbach’s plexus lies between the 2.
Adventitia (outermost)

Question 13

What is the definition of achalasia?

Answer 13

Oesophageal motility disorder characterised by inadequate relaxation of LES and non peristaltic contractions in distal 2/3 of oesophagus due to degeneration of inhibitory neurons.

Question 14

Which age group does Achalasia mostly occur in?

Answer 14

Middle aged individuals

Question 15

What is the cause of primary and secondary achalasia?

Answer 15

Primary - unknown

Secondary - mechanical cause of obstruction eg malignancy that mimics achalasia (eg oesophageal cancer, amyloidosis, sarcoidosis)

Question 16

What is the pathophysiology behind achalasia?

Answer 16

Swallowing controlled by excitatory neurohormonal substances. Atrophy if inhibitory neurons in auerbach’s plexus leads to lack of inhibitor neurotransmittors -> inability to relax LES and increased resting pressure and dysfunctional peristalsis. -> oesophageal dilation proximal to LES.

Question 17

What are the 4 clinical features of achalasia?

Answer 17

Dysphasia
Regurgitation
Retrosternal pain and cramps
Weight loss

Question 18

Which diagnostic tests should be done to confirm achalasia?

Answer 18

Initial - upper endoscopy and barium swallow.
Oesophageal manometry to establish diagnosis.
If manometry not conclusive, do. Oesophagram to confirm.
Endoscopy done to rule out pseudo achalasia.

Question 19

What 2 signs do you look out for in oesophageal barium swallow for achalasia?

Answer 19

Bird beak sign - dilation of proximal oesophagus with stenosis of the GE junction

Delayed barium emptying or barium retention

Question 20

What is the purpose of a lab upper endoscopy for achalasia? And what else will it show?

Answer 20

Rule out pseudoachalasia

Usually normal. May show retained good in oesophagus. If malignancy suspected, biopsy and endoscopic ultrasound

Question 21

What will an oesophageal manometry show for achalasia?

Answer 21

Peristalsis is absent or uncoordinated in lower 2/3 of oesophagus.
Incomplete or absent LES relaxation
High LES resting pressure
No evidence of mechanical obstruction

Question 22

What will a chest X-ray show for achalasia?

Answer 22

Widened mediastinum
Air fluid level on lateral view
Possible absence of gastric air bubble

Question 23

What is the differential diagnosis for achalasia?

Answer 23

Oesophageal cancer
Schatzki ring
Oesophageal stricture
Chagas disease
Extrinsic compression
Scleroderma

Question 24

What are the treatment options for achalasia?

Answer 24

If low surgical risk

Pneumatic dilation surgery
LES myotomy
Peroral endoscopic myotomy

If high surgical risk

Botulinum toxin injection in LES
if failure, nitrates or calcium channel blockers

Question 25

What does a pneumatic dilation surgery di?

Answer 25

Dilation of LES that tears the surrounding muscle fibres with the help of a balloon

Question 26

What does a LES myotomy do?

Answer 26

Surgical procedure in which the LES is incised longitudinally to re-enable passage of food or liquids in stomach

Question 27

What does a peroral endoscopic myotomy do?

Answer 27

Myotomy (cutting of muscular layer) of inner circular muscle layer of LES

Question 28

What are the complications of achalasia?

Answer 28

Pulmonary complications. Eg pneumonia, abscess, asthma - caused by aspiration

Mega-oesophagus

Increased risk of oesophageal cancer