Achalasia

Achalasia is a condition that involves chronic and progressive obstruction to the passage of contents through the lower oesophageal sphincter. It is characterised by defective peristalsis in the oesophagus combined with an elevated lower oesophageal sphincter pressure which fails to relax in response to the oesophageal swallowing wave.

Clinical features of achalasia

Patients with achalasia present with dysphagia to solids and liquids, sometimes associated with pain, regurgitation and weight loss. It is an unusual disease affecting 1 in 100 000 of Western populations (Dent 2000). It usually develops in middle or late adult life and the aetiology is unknown. Dysphagia develops slowly, and is initially intermittent. It is worse for solids and is eased by drinking liquids, standing and moving around after eating. Heartburn does not occur, since the closed oesophageal sphincter prevents gastro-oesophageal reflux. Some patients experience episodes of severe chest pain due to oesophageal spasm ('vigorous achalasia'), although this disappears as the body of the oesophagus loses peristaltic activity. Patients may worry that this pain is related to heart disease and gastrointestinal nurses should be in the position to provide reassurance and support in such situations.

Investigations for achalasia

A chest radiograph may be abnormal in late disease, with widening of the mediastinum from gross oesophageal dilation and features of aspiration pneumonia. A barium swallow will display narrowing of the lower oesophagus. In late disease the oesophageal body is dilated, with absence of peristalsis. Manometry is diagnostic and may demonstrate the failure of relaxation in the lower oesophagus. The nurse should provide the patient with clear information prior to this investigation to allay potential concerns.

Management of achalsia

Symptoms of achalasia may be minimised by eating slowly, chewing well, drinking fluids with meals, and sitting up whilst eating.

Endoscopic treatment

Forceful pneumatic dilation using an endoscopically positioned balloon disrupts the oesophageal sphincter and improves symptoms in 80% of patients. Some patients require more than one dilation but those requiring frequent dilation are best treated surgically. Endoscopically directed injection of botu-linum toxin into the lower oesophageal sphincter induces clinical remission, but late relapse is common.

Surgical treatment

Surgical myotomy ('Heller's operation') is carried out by open operation or by a laparoscopic approach and is an extremely effective, although more invasive, option. Both pneumatic dilation and myotomy may be complicated by gastro-oesophageal reflux, and this can lead to severe oesophagitis because oesopha-geal clearance is so poor in these patients. For this reason Heller's myotomy is sometimes accompanied by an anti-reflux operation. Acid-suppressing drug therapy, using a proton pump inhibitor, is often necessary following surgical or endoscopic intervention for achalasia.

Evidence-based guidelines for the management of achalasia have been published in the American Journal of Gastroenterology (1999).

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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