Achalasia is the second most common functional disorder of the esophagus that requires surgery, after reflux disease.
In achalasia, damage occurs to the nerve cells located between the muscle layers of the esophagus. As a result, there is no contraction in the muscles in the esophagus and the lower esophageal valve is damaged. Insufficiency of opening develops. As the duration of the disease increases, the esophagus expands.
Although the exact cause is unknown, hereditary, degenerative, autoimmune and infectious factors have been blamed.
Achalasia can be seen at any age; However, the age of onset is generally between 30-60 years of age and peaks in the 40s. It is more common in men.
The most common and early symptom of achalasia is difficulty swallowing (dysphagia). Difficulty in swallowing may begin suddenly or may be intermittent and recurrent. It becomes permanent in advanced stages. While it initially occurs against solid foods, in advanced stages it occurs against both solid and liquid foods.
Regurgitation of undigested food coming back into the mouth is seen in 75% of patients.
60% of patients lose weight.
Chest pain is a complaint seen in approximately 40% of patients in the early stages of the disease. As the esophagus expands, the complaint decreases.
Diagnostic Tests
1.Barium passage radiography: The esophagus is seen as enlarged. Since the lower valve of the esophagus does not relax, the esophagus narrows properly towards the lower part (bird's beak appearance). The passage of contrast material into the stomach slows down.
2.Gastroscopy/Endoscopy: In endoscopy, the esophagus is seen wide. Stomach residues can be seen inside the esophagus. The lower esophagus valve is not opened by giving air, it is passed into the stomach with the pressure applied by the device.
3.Manometry: It is the main test that diagnoses achalasia. It is done to confirm the diagnosis. If achalasia is suspected, a manometry test should be performed even if the passage test and/or endoscopy are normal.
Manometry shows loss of contraction in the muscles in the esophagus; There is also loss of relaxation of the lower esophageal valve. The lower esophageal valve pressure is high.
The most important disease that can be confused with achalasia is tumors affecting the upper part of the stomach. Differentiation of achalasia from stomach cancer by endoscopy, endo USG, abdominal USG and tomography
Treatment
The aim of the treatment is to eliminate the complaints by allowing the food from the esophagus to empty easily into the stomach.
The 2 most effective treatment methods are balloon dilatation and surgery (laparoscopic Heller myotomy and partial funduplication). Success results are highest in surgical treatment. Difficulty in swallowing disappears completely with a rate of 85-100% with surgical treatment.
Surgical treatment should be applied to patients who do not receive adequate response even after 2 balloon dilatations.
The chance of success of balloon dilation is much less in patients under the age of 40. Therefore, surgical treatment may be recommended without dilatation in young patients in this group.
In laparoscopic Heller Myotomy, the muscle fibers in the lower 6 cm of the esophagus and the first 2 cm of the upper part of the stomach are cut and separated. Funduplication is performed to prevent gastric reflux after surgery.
For balloon dilatation and surgery. In high-risk cases, treatment with drugs such as botulinum toxin, nitrates or calcium channel blockers may be applied; but its therapeutic effects are very low.
There is a 3-5% risk of perforation in the esophagus with each balloon dilatation procedure applied.
The chance of success of botulinum toxin injection is less than balloon dilatation. In repeated applications. It causes scar formation, making the operation difficult.
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