Achalasia

Question 1

What is achalasia?

Answer 1

It is defined as a condition in which there is failure of oesophageal peristalsis and contraction of the lower oesophageal sphincter

Question 2

What is the pathophysiological cause of achalasia?

Answer 2

It is due to a degenerative loss of ganglia within the Auerbach’s nerve plexus

Question 3

What are the six clinical features of achalasia?

Answer 3

Dysphagia of Liquids & Solids

Heartburn

Regurgitation

Aspiration Pneumonia

Nausea & Vomiting

Weight Loss

Question 4

What are the three investigations used to diagnose achalasia?

Answer 4

Chest X-Ray (CXR)

Barium Swallow

Oesophageal Manometry

Question 5

What are the two CXR features of achalasia?

Answer 5

Widened Mediastinum

Air-Fluid Level

Question 6

What are the three features of achalasia on barium swallow?

Answer 6

Widened Oesophagus

Air-Fluid Level

Bird’s Beak Sign

Question 7

What is the birds beak sign on CXR?

Answer 7

It is the appearance of a tight stricture at the gastrooesophageal junction

Question 8

What is the gold standard investigaion used to diagnose achalasia?

Answer 8

Oesophageal manometry

Question 9

What is oesophageal manometry?

Answer 9

It involves a catheter being inserted through the nose and passed into the oesophagus

This allows measurement of the oesophageal sphincter tone and the force exerted by oesophageal muscles

Question 10

What is a feature of achalasia on oesophageal manometry?

Answer 10

Excessive lower oesophageal sphincter tone, which doesn’t relax on swallowing

Question 11

What are the two pharmacological management options used to manage achalasia?

Answer 11

Calcium Channel Blockers

Nitrates

Question 12

When are calcium channel blockers used to manage achalasia?

Answer 12

When individuals are unsuitable for pneumatic dilation or surgical management, and botulinum injections have been deemed as unsuccessful

However, it is important to note that there is limited treatment effect with several side effects

Question 13

Name a calcium channel blocker used to manage achalasia

Answer 13

Nifedipine

Question 14

When are nitrates used to manage achalasia?

Answer 14

When individuals are unsuitable for pneumatic dilation or surgical management, and botulinum injections have been deemed as unsuccessful

However, it is important to note that there is limited treatment effect with several side effects

Question 15

Name a nitrate used to manage achalasia

Answer 15

Nitroglycerin

Question 16

What are the two non-surgical management options used to manage achalasia?

Answer 16

Pneumatic Dilation

Botulinum Toxin Injection

Question 17

When is pneumatic dialtion used to manage achalasia?

Answer 17

It is the first line management option of achalasia, in young individuals without multiple comorbidities

Question 18

What is pneumatic dilation?

Answer 18

It involves endoscopic insertion of a balloon into the oesophageal sphincter and inflated to enlarge the opening

Question 19

When is botulinum toxin injections used to manage achalasia?

Answer 19

It is the first line management option of achalasia, in elderly individuals with multiple comorbidities

Question 20

How are botulinum toxin injections used to manage achalasia?

Answer 20

It is injected into the oesophageal sphincteric muscle to relax it

Question 21

What is the surgical management option of achalasia?

Answer 21

Heller Cardiomyotomy

Question 22

When is heller cardiomyotomy used to manage achalasia?

Answer 22

It should be considered in cases where achalasia is recurrent, and individuals are young without multiple comorbidities

Question 23

What is heller cardiomyotomy?

Answer 23

It involves an incision of the muscle at the lower end of the oesophageal sphincter