What is Achalasia? How is the treatment done?

When we eat a food, it starts from the mouth and passes through the esophagus, stomach, small intestine and large intestine, respectively. The smooth progress of the food throughout this process depends on the proper peristaltic movement. Peristaltic movement; It is the pushing of the organ contents forward with circular movements seen in organs such as the esophagus and intestines in the digestive system. In this way, the food we eat continues its movement between the organs without us being aware of it. It is the nerve cells between the layers that make up the organs that enable this movement to take place regularly.

What is Achalasia?

During swallowing, the lower esophageal sphincter, which is located at the junction of the esophagus and stomach, does not open as it should, It causes food not to pass into the stomach and accumulate in the esophagus. As a result of the accumulation of these nutrients in the esophagus, enlargement occurs. The movement disorder of the muscles in the esophagus is called achalasia.

Who Gets Achalasia?

Achalasia is a rare disease. 1 person out of every 100,000 people has this disease. Achalasia can occur at any age. However, it has been observed that the incidence of the disease increases with increasing age.

What Causes Achalasia?

There may be more than one cause of achalasia. Therefore, finding a specific cause can be difficult. The cause can be genetic or due to an infection, or it can be caused by an autoimmune condition. The herpes virus is thought to play a role in infectious achalasia. Autoimmune diseases are diseases caused by immune system (immune system) cells in the body. Normally, immune cells protect the body against harmful microorganisms such as viruses and bacteria.
It neutralizes microorganisms and prevents them from being infected. Autoimmune diseases occur when these immune system cells mistakenly perceive the body's own cells as foreign cells and try to neutralize them. In achalasia, the immune system cells attack the nerve cells that provide the movement of the esophagus and cause the functions of these nerve cells to deteriorate.

What are the Symptoms of Achalasia?

• Hardness in patients and especially liquid foods difficulty in swallowing (dysphagia),
• In the later stages of the disease; Recurrent infections such as bronchitis, eumonia (pneumonia) as a result of the escape of food accumulated in the esophagus to the lungs,
• Chest pain,
• Cough,
• Burning,
• Heartburn,
• Feeling of fullness in the throat,
• Weight loss.

Regurgitation, that is, the return of food accumulated in the enlarged esophagus to the mouth without swallowing, are common symptoms . Regurgitation increases especially in supine position, during sleep and after meals.

How to Diagnose Achalasia?

The diagnosis of the disease can be made approximately 5 years after the symptoms appear. This is because the disease starts mildly and progresses very slowly.
Diagnosis can be made with barium esophagus (esophagus) graphy, endoscopy and manometer (pressure measurement).
In barium radiography, the patient is filmed by drinking barium. In the film, it can be seen that the muscle at the junction of the esophagus and the stomach is contracted and the esophagus located above this muscle is enlarged. According to this enlargement, the disease is divided into 3 stages:
Stage I (minimal): Diameter of the esophagus <4 cmStage II (medium): Diameter of the esophagus 4-6 cmStage III (advanced): Diameter of the esophagus > 6 cm
Achalasia In the early stages, the enlargement of the esophagus may not be evident. It is not possible to make a diagnosis by only looking at this method, especially in patients in the early period.
As tumors that involve the junction connecting the esophagus and stomach or that can exert external pressure on this junction may cause similar symptoms with achalasia, endoscopy should be performed to show that the symptoms are related to achalasia. The definitive diagnosis is made by the manometer method. contraction movements are observed. Absence of peristaltic movement, increased pressure of the lower esophageal sphincter (the muscle ring connecting the esophagus to the stomach), and inability to relax adequately during swallowing are typical signs of achalasia on manometry.

What are the Types of Achalasia?

Patients with achalasia with high resolution manometer

• type I (classic),
• type II (esophageal) accompanied by compression)
• is classified as type III (spastic achalasia).

Clinical course of the disease and treatment In response, it is important which type of achalasia the patient has.

How is Achalasia Treated?

There are some methods used in the treatment of achalasia:

Medical treatment: Drug treatment is started in patients with achalasia where the disease has a mild course. Nitrate group and calcium channel blockers drugs can be preferred.

Botox injection: Botulinum toxin is injected into the esophagus and stomach junction, reducing the contraction and therefore the pressure in the junction, which is also a treatment option. However, since the effect of this injection will disappear after a period of 6-12 months, the procedure may need to be repeated. . Recovery is achieved with this method in approximately 70% of patients. Despite the fact that the dilatation procedure is performed twice, the complaints continue or the young patients in whom the first dilatation procedure is not successful require surgical operation. The most important complication of the dilatation procedure is perforation of the esophagus. The risk of perforation is approximately 2%. The risk of reflux after application is less than surgical methods

Surgical treatment: One option is a classical technique called "Heller Myotomy". It is the process of cutting the outer layers of the esophagus and the parts of the stomach close to the junction. In this way, it is aimed to open the normal passageway for nutrients by reducing the contraction around the junction. Perforation and reflux are important complications. Another option in surgery is POEM (per-oral endoscopic myotomy). An important advantage of this method is that it provides treatment without any incision or hole in the body. Advancing an endoscope through the mouth is the cut of the thickened muscle layer that forms the junction by entering through the middle layer of the esophagus.

Today, it is the most successful and up-to-date method in the treatment of achalasia. Although it has certain risks such as reflux, the treatment rate is high.

What Happens If Achalasia Is Not Treated?

When achalasia is not treated, it may have an effect such as weakening the patient. In particular, malnutrition can occur as a result of excessive weight loss. This is for people of all ages. China is a serious situation. Inability to perform daily activities due to insufficient calorie intake, fatigue and weakness occur. Many diseases, from susceptibility to infections to osteoporosis, can be seen in patients due to the inability to take vitamins and minerals properly. Insufficient fluid intake is also a serious problem. In untreated patients, the nutrients accumulated in the esophagus come back to the mouth, especially in the supine position. In the meantime, the escape of food into the respiratory tract (aspiration) can cause lung infections and aspiration pneumonia (pneumonia). These are serious problems that can be life-threatening. Therefore, treatment for achalasia should not be delayed or delayed.

What Should Achalasia Patients Do in Their Daily Lives?

Patients with achalasia should chew their food thoroughly and eat slowly, drink plenty of water with meals, It is necessary to avoid eating before going to bed. It may be beneficial to sleep in a bed with a raised head or with a high pillow. Avoiding acidic vegetables and derivatives such as coffee, alcohol, chocolate, pickles, onions, garlic, tomatoes, and carbonated beverages, which also exacerbate reflux, may be effective in reducing the severity of the disease.

Does Achalasia Increase the Risk of Cancer?

Since it cannot pass into the stomach, the food accumulating in the esophagus causes irritation of the mucosa, that is, the innermost part of the esophagus. Irritation and accompanying inflammation (inflammation) is an important risk factor for esophageal cancer. This leads to a 14-fold increase in the risk of cancer in achalasia patients compared to the general population. Treating the disease does not eliminate this risk. Therefore, patients should be followed regularly.

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