Achalasia
"Through a thorough evaluation of your case and the implementation of a multidisciplinary approach, we will design an individualized treatment plan, including endoscopic or surgical treatments."
DR. JOSE MARÍA RIESCO LÓPEZ
PERSON IN CHARGE. DIGESTIVE DEPARTMENT
What is esophageal achalasia?
Achalasia is a chronic esophageal disorder that affects the normal functioning of the esophagus, the muscular tube that connects the mouth to the stomach.
In a person without achalasia, the muscles of the esophagus contract and relax to allow food to pass into the stomach. However, in patients with achalasia, the esophageal muscles do not relax properly, making it difficult for food to pass through and causing uncomfortable symptoms.
In the treatment of a patient with achalasia, there are both endoscopic and surgical therapeutic options designed to relieve symptoms and improve esophageal functionality. Each therapeutic approach has its own indications and considerations, so the most appropriate treatment will be determined based on the individual patient's evaluation and the characteristics of his or her disease.
At the Clínica we have an Endoscopy Unit equipped with the latest technology and professionals with extensive experience in performing endoscopic diagnostic and therapeutic techniques.
What are the symptoms of achalasia?
Achalasia can manifest with a variety of symptoms that can vary in intensity and presentation at different stages of the disease.
Early symptoms
- Dysphagia: Dysphagia, or difficulty swallowing, is one of the most common early symptoms of achalasia. Patients may experience difficulty swallowing solid foods and liquids, as well as the sensation of food getting stuck in the chest or throat. Dysphagia tends to gradually worsen over time.
- Regurgitation: Regurgitation is another early symptom of achalasia. It consists of the passive return of food and liquids from the esophagus into the mouth without straining or vomiting. It may occur shortly after eating or even during sleep, which can be uncomfortable and disturbing.
- Chest pain: Some patients may experience intermittent chest pain, which may be mistaken for cardiac pain. This pain is often described as tightness or pressure in the chest and may radiate to the left arm or jaw.
Late symptoms
- Weight loss: As the disease progresses, patients may experience gradual weight loss. This is due to difficulty swallowing adequate amounts of food due to persistent dysphagia.
- Megaesophagus: In advanced stages of achalasia, the esophagus may become dilated and enlarged, known as megaesophagus. This occurs due to the accumulation of food and fluid in the esophagus, as the passage to the stomach is blocked. Megaesophagus can cause a feeling of fullness in the chest and contribute to frequent regurgitation.
- Pulmonary aspiration: In severe cases of achalasia, food and liquids may regurgitate into the airway and lungs, which can result in recurrent episodes of aspiration pneumonia. This occurs due to difficulty coordinating swallowing and proper closure of the lower esophageal sphincter.
- Chronic cough: The presence of food and liquids in the esophagus can trigger a persistent cough. This chronic cough may be especially pronounced after meals or at bedtime.
It is important to note that the symptoms of achalasia can vary widely among patients. Some individuals may present with only early symptoms over a long period, while others may develop late symptoms more rapidly.
Do you have any of these symptoms?
You may have achalasia
What are the causes of esophageal achalasia?
Achalasia is a disease of the esophagus whose exact cause is not yet known with certainty. However, several factors have been identified that may contribute to the development of this condition.
- Nervous system abnormalities: It is believed that abnormalities in the nervous system may play an important role in the development of achalasia. In particular, dysfunction of the ganglion cells of Auerbach's myenteric plexus, which controls the peristaltic movements of the esophagus, has been observed. These nerve alterations may affect the ability of the lower esophageal sphincter to relax properly and allow the passage of food into the stomach.
- Hereditary factors: There is evidence to support a genetic component in the development of achalasia. Some cases of achalasia have been found to have a familial pattern, suggesting a genetic predisposition to the disease. However, the specific genes involved have not yet been identified.
- Autoimmune disorders: It has been postulated that achalasia may be the result of an abnormal autoimmune response in which the body's immune system mistakenly attacks nerve cells in the esophagus. This theory is based on the observation that many patients with achalasia also have other autoimmune disorders, such as Hashimoto's thyroiditis or Chagas disease.
Types of achalasia
Esophageal achalasia
Esophageal achalasia is the most common form of achalasia and is characterized by lower esophageal sphincter (LES) dysfunction and a lack of adequate esophageal peristalsis. The LES is a muscular ring at the junction between the esophagus and the stomach, responsible for relaxing to allow the passage of food into the stomach during swallowing. In esophageal achalasia, this sphincter does not relax properly, causing partial or complete obstruction of the passage of food.
Cricopharyngeal achalasia
Cricopharyngeal achalasia, also known as pharyngeal achalasia, is a less common form of achalasia that affects the cricopharyngeal sphincter musculature. The cricopharyngeal sphincter is located at the top of the esophagus, at the junction with the pharynx. Its function is to relax during swallowing to allow the passage of food into the esophagus.
In cricopharyngeal achalasia, the cricopharyngeal sphincter does not relax properly, resulting in difficulty initiating swallowing and a feeling of blockage in the throat. This can cause regurgitation of food into the mouth and difficulty swallowing even liquids. Unlike esophageal achalasia, cricopharyngeal achalasia is not usually associated with esophageal dilation.
How is achalasia diagnosed?
The first step in diagnosing achalasia is a detailed medical history and physical examination. The doctor will ask about symptoms, their duration, and any factors that make them worse or better.
There are several tests that physicians can use to diagnose achalasia, including:
- Esophageal Manometry: This test measures the pressure in the esophagus and can show if the lower esophageal sphincter is working properly.
- Barium X-ray: During this test, the patient is asked to swallow a barium solution. X-rays are then taken to see how the barium flows through the esophagus.
- Endoscopy: This procedure uses a thin, flexible tube with a camera to examine the esophagus and stomach.
How is esophageal achalasia treated?
Available treatments for achalasia can relieve symptoms and improve quality of life.
Pharmacological treatment
Drug treatment plays an important role in the management of achalasia, especially in the early stages of the disease. Although medications cannot cure achalasia, they can provide symptomatic relief and improve patients' quality of life.
Lower esophageal sphincter relaxant (LES) drugs
Drugs that act as LES relaxants are used to facilitate the passage of food through the esophagus and relieve dysphagia. Among them, the most common are calcium channel blockers, such as nifedipine and diltiazem. These drugs act by relaxing the smooth muscle of the LES and allowing a better opening during swallowing. However, their efficacy may vary among patients and they may be associated with side effects such as hypotension and dizziness.
Medications that improve esophageal motility
Some medications can help improve esophageal motility in patients with achalasia. These include dopamine receptor agonists such as bromocriptine and metoclopramide.
These drugs act by stimulating esophageal muscle contraction and promoting adequate emptying of the esophagus. However, it is important to note that these drugs can have side effects, such as nausea, drowsiness and movement disorders.
Medications to reduce acid production
Some patients with achalasia may experience acid reflux symptoms due to LES dysfunction. In these cases, proton pump inhibitors (PPIs), such as omeprazole and esomeprazole, may be prescribed to reduce acid production in the stomach and relieve symptoms of heartburn and regurgitation.
It is essential that drug treatment be administered under the supervision of a specialist physician, who will assess the patient's individual response and adjust the dose and duration of treatment as necessary. In addition, it is recommended to combine drug treatment with dietary changes, such as eating soft foods and avoiding large meals before bedtime, to minimize symptoms and improve swallowing.
Endoscopic treatment
Nonsurgical treatment is an option to consider in the management of achalasia, especially in patients who are not candidates for surgery or who wish to explore less invasive options. Although these approaches do not cure achalasia, they can alleviate symptoms and improve patients' quality of life.
Esophageal pneumatic dilation
Esophageal dilation is a procedure in which an endoscope with an inflatable balloon or dilators is used to widen the lower esophageal sphincter (LES). This procedure aims to break down the muscle fibers of the LES and improve the passage of food into the stomach. Esophageal dilation may provide short-term symptomatic relief, but repeated sessions may be required to maintain results.
Botulinum toxin injection
Botulinum toxin injection into the LES is another nonsurgical approach used in the treatment of achalasia. Botulinum toxin acts by temporarily relaxing the sphincter, thereby improving the ability to swallow. However, the effects of botulinum toxin are temporary and may require periodic reinjections.
Peroral endoscopic myotomy
Peroral endoscopic myotomy (POEM) has become a highly effective therapeutic option. POEM is a minimally invasive endoscopic procedure that aims to relieve symptoms and improve esophageal function in patients with achalasia.
During peroral endoscopic myotomy, an incision is made in the muscle layer of the lower esophageal sphincter (LES) using an advanced flexible endoscope. This incision allows adequate relaxation of the sphincter, improving the passage of food into the stomach. POEM is performed under deep sedation and endoscopic guidance, and requires a medical team specialized in advanced endoscopy.
The POEM technique has demonstrated excellent results in relieving achalasia symptoms and improving esophageal function. Numerous clinical studies have supported its efficacy, with success rates exceeding 90%. In addition, POEM offers significant advantages over traditional surgery, such as faster recovery, less postoperative pain and lower risk of complications.
It is important to keep in mind that peroral endoscopic myotomy is not suitable for all patients with achalasia, and treatment selection should be based on individualized assessment. Some patients may have contraindications due to comorbidities or atypical anatomic features. Therefore, it is essential to have an experienced medical team specialized in endoscopy to determine the best therapeutic option.
Surgical treatment
Surgical treatment is an important option in the management of achalasia, especially in more advanced cases or when other treatments have not provided adequate relief of symptoms. The most commonly used surgery to treat achalasia is Heller myotomy, a procedure that seeks to relieve lower esophageal sphincter (LES) obstruction and restore normal esophageal function.
During Heller myotomy, an incision is made in the LES to release the tension and stiffness causing the dysfunction. This allows the sphincter to relax properly and open during swallowing, facilitating the passage of food into the stomach. The procedure is performed by laparoscopic surgery, which means that small incisions are made in the abdomen through which surgical instruments and a camera are inserted to guide the surgeon during the intervention.
Laparoscopic Heller myotomy has proven to be an effective treatment in the management of achalasia, with success rates exceeding 90% in terms of symptom relief and improved esophageal function. In addition, Heller surgery can also be combined with fundoplication, which involves wrapping part of the stomach around the esophagus to prevent acid reflux.
It is important to note that laparoscopic Heller surgery is an invasive procedure that requires general anesthesia and a postoperative recovery period. Although it is considered safe and effective, there may be potential risks and complications associated with any surgical procedure. It is essential that the patient discuss in detail with the surgeon the benefits, risks and expectations before undergoing surgery.
In some cases, when Heller myotomy is not possible or not appropriate, other surgical options may be considered. These include cardioplasty or esophagocardioplasty, which involve partial resection of the esophagus and junction with the stomach, or even total replacement of the esophagus with a segment of intestine.
Where do we treat it?
IN NAVARRE AND MADRID
The Department of Digestive
of the Clínica Universidad de Navarra
The Digestive Department of the Clinica Universidad de Navarra is composed of a multidisciplinary team of specialists who are experts in the diagnosis and treatment of diseases of the digestive tract.
Our objective is that each diagnosis be carefully established and the treatment plan adjusted to each patient.
Why at the Clinica?
- Medical specialists who are national references.
- Specialized nursing team.
- Endoscopy Unit and High Risk Digestive Tumor Prevention and Consultation Unit to offer the best care to our patients.
Our team of professionals
Digestive specialists with experience in treating achalasia
