ACHALASIA�

SURGICAL NURSING II

BY AMOS OWUSU

OESOPHAGEAL MOTILITY DISORDER

ACHALASIA

• It’s absent or ineffective peristalsis of the distal esophagus, accompanied by failure of the esophageal sphincter to relax in response to swallowing.
• Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest.

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Dilated proximal Oesophagus

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Distal Oesophageal narrowing

• (bird’s

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• Achalasia is a rare disease of the muscle of the esophagus (swallowing tube).
• The term achalasia means "failure to relax" and refers to the inability of the lower esophageal sphincter (a ring of muscle situated between the lower esophagus and the stomach) to open and let food pass into the stomach.
• As a result, patients with achalasia have difficulty in swallowing food.

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Incidence �

• It may occur at any age, but is most common in middle-aged or older adults
• Achalasia may progress slowly and occurs most often in people 40 years of age or older.

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Cause�

• A muscular ring at the point where the esophagus and stomach come together (lower esophageal sphincter) normally relaxes during swallowing.
• In people with achalasia, this muscle ring does not relax as well.
• The reason for this problem is damage to the nerves of the esophagus.
• This problem may be inherited in some people.

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Clinical Features cont’�

• Backflow (regurgitation) of food
• Chest pain, which may increase after eating or may be felt in the back, neck, and arms
• Cough
• Difficulty swallowing liquids and solids (dysphagia to solids and liquids)
• Heartburn (pyrosis)

Clinical Features�

• Unintentional weight loss
• There may be secondary pulmonary complications from aspiration of gastric contents.
• The patient has a sensation of food sticking in the lower portion of the esophagus
• nocturnal cough and recurrent aspiration

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Diagnostic Measures�

• endoscopy
• The diagnosis is confirmed by manometry, a process in which the esophageal pressure is measured by a radiologist or gastroenterologist

Diagnostic Measures cont’�

• X-ray studies show esophageal dilation above the narrowing at the gastroesophageal junction.
• Barium swallow,
• computed tomography (CT) of the esophagus

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MANAGEMENT

• GOAL OF MANAGEMENT

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• reduce LES pressure and
• increase emptying

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Management�

• The patient should be instructed to eat slowly and to drink fluids with meals as a temporary measure.
• Administer prescribed calcium channel blockers and nitrates.
• They used to decrease esophageal pressure and improve swallowing.

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Management

• Injection of botulinum toxin (Botox) to quadrants of the esophagus via endoscopy has been helpful because it inhibits the contraction of smooth muscle.
• Periodic injections are required to maintain remission.

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Intersphincteric Injection of Botulinum Toxin

Management�

• If these methods are unsuccessful, pneumatic (forceful) dilation or surgical separation of the muscle fibers may be recommended

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Pneumatic Dilatation

Management cont’�

• Achalasia may be treated surgically by esophagomyotomy.

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• The procedure usually is performed laparoscopically, either with a complete lower esophageal sphincter myotomy and an antireflux procedure, or without an antireflux procedure.

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Management

• The esophageal muscle fibers are separated to relieve the lower esophageal stricture.
• Although patients with a history of achalasia have a slightly higher incidence of esophageal cancer, long-term follow-up with esophagoscopy for early detection has not proved beneficial.

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Management cont’�

• Achalasia may be treated conservatively by pneumatic dilation to stretch the narrowed area of the esophagus.
• Pneumatic dilation has a high success rate.
• Although perforation is a potential complication, its incidence is low.

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Management cont’�

• The procedure can be painful; therefore, moderate sedation in the form of an analgesic or tranquilizer, or both, is administered for the treatment.
• The patient is monitored for perforation.
• Complaints of abdominal tenderness and fever may be indications of perforation

COMPLICATION

• Aspiration | pneumonia
• Chronic irritation | carcinoma oesophagus

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THANK YOU