Dysphagia, Diffuse Spasm, and Achalasis: Motor Disorder of the Esophagus
Failure of peristalsis in the esophageal body or failure of the lower esophageal sphincter to relax will result in dysphagia or difficulty in swallowing. Some people show abnormally high pressure waves as peristalsis propagates past the recording ports on manometric catheters. This condition called nutcracker esophagus, is sometimes associated with chest pain that may be experienced as angina-like pain.
On diffuse spasm, organized propagation of the peristaltic behavioral complex fails to occur after a swallow. Instead, the act of swallowing results in simultaneous contraction all along the smooth muscle esophagus. On manometric tracings, this response is observed as a synchronous rise in intraluminal pressure at each of the recording sensors.
In achalasis of the lower esophagus sphincter, the sphincter fails to relax normally during a swallow. As a result, the ingested material does not enter the stomach and accumulates in the body of the esophagus. This leads to megaesophagus, in which distension and gross enlargement of the esophagus are
evident. In advanced untreated cases of achalasis, peristalsis does not occur in response to a swallow.
Achalasis is a disorder of inhibitory motor neurons in the lower esophageal sphincter. The number of neurons in the lower esophageal sphincter is reduced, and the levels of the inhibitory neurotransmitter VIP and the enzyme NO synthase are diminished. This degenerative disease results in a loss of the inhibitory mechanism for relaxing the sphincter with appropriate timing for a successful swallow.
Symptoms of achalasis include progressive dysphagia, noted by essentially all patients; regurgitation immediately after meals (>70%); odynophagia (30%); and aspiration, with resultant bronchitis and pneumonia. Some patient experience chest pain due to esophageal spasms
The diagnosis is suggested by a chest x-ray, which often shows a fluid filled, dilated esophagus and absence of gastric air bubble. A barium esophagogram shows tapering (bird’s beak) of the distal esophagus and dilated proximal esophagus. Esophageal manometry is the
definitive diagnostic test for the achalasis.
Achalasis is managed by medical and surgical method; medical treatment is aimed at decreasing the LES (lower esophageal sphincter) tone and includes nitrates, calcium channel blockers and endoscopic injection of botulism toxin.
Surgical treatment with a modified Heller esophagomotomy has been shown to produce excellent results in 95% of patients .Video-assisted thoracoscopic approaches have been tried. More recently, laparoscopic esophagomotomy combined with partial Fundaplication has been has been reported, and it is rapidly being adopted by most centers as the primary surgical option.
References:
- The Washington Manual of surgery, 5th edition.
- Medical physiology, Lippincott Williams & Wilkins 3rd edi.
- Harrison’s Principles of Internal Medicine, 17th edition.
- Davidson’s Principles and Practice of Medicine, 20th Edition
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