Esophageal Disease

Question 1

What is achalasia?

Answer 1

• Esophageal motility disorder
• Characterized by inadequate LES relaxation
• Progressive loss of peristaltic function

Question 2

What is the pathophysiology behind achalasia?

Answer 2

• Inflammatory degeneration of neurons at the LES
• Uncontested cholinergic signalling at the LES
• Incomplete LES relaxation
• Proximal progression
• Eventual aperistalsis

Question 3

Who presents with achalasia? (age, gender, incidence)

Answer 3

• Between 30 - 60 yrs
• Equal M = F
• Incidence 1 in 100,000

Question 4

Symptoms of achalasia

Answer 4

• Dysphagia to solids and liquids
• Regurgitation of undigested foods
• Chest pain
• Weight loss

Question 5

What is the initial and confirmatory test to diagnose achalasia?

Answer 5

• Barium esophagram: “bird’s beak” narrowing of LES

- Esophageal manometry: no relaxation at LES

Question 6

What would a chest x-ray show in someone with achalasia?

Answer 6

Dilated esophagus

No air in the stomach

Question 7

Why would you perform an EGD in someone with achalasia?

Answer 7

To rule out other causes of dysphagia, such as structural obstructions (rings, webs), and malignancy

Question 8

What is this sign on barium esophagram?
What does it represent?
(insert xray of bird’s beak)

Answer 8

Bird’s beak sign

Achalasia

Question 9

How would you treat achalasia? (in order of preference)

Answer 9

1. Endoscopic pneumatic dilatation
2. Laparascopic surgical myotomy (fundoplication is also recommended after myotomy to prevent reflux) - this is considered first-line equivalent to endoscopic dilatation
3. Endoscopic injection of botulinum toxin
4. Pharmacologic therapy - CCB, long-acting nitrates

Question 10

What is the mechanism of action of botulinum toxin injections for the treatment of achalasia?

Answer 10

Botulinum toxin inhibits acetylcholine release, resulting in LES relaxation.

Has a relapse rate of 50%.
Often needs re-treatment in 6 months.

Question 11

What kind of cancer is associated with achalasia?

Answer 11

Squamous cell esophageal cancer

However, as it is low risk, surveillance is not recommended

Question 12

What is pseudoachalasia?

Answer 12

Achalasia-like pattern of distal esophageal narrowing from causes other than primary denervation of the LES.

(e.g. tumors at gastroesophageal junction may lead to myenteric plexus infiltration)

Question 13

What is the surveillance and management for the following degrees of Barrett’s esophagus?

• BE with no dysplasia
• BE with low grade dysplasia
• BE with high grade dysplasia

Answer 13

1) EGD every 3-5 yrs
2) EGD every 6-12 mos
3) aggressive surveillance, endoscopic ablation, or esophagectomy