Achalasia Cardia- Gastroenterology

Achalasia cardia is a form of achalasia where the lower esophageal sphincter (LES) does not function properly and does not relax and open when the person swallows. This means that food cannot properly enter the stomach leading to Gastroesophageal Reflux Disease (GERD) and other problems.

This can result in complications like aspiration pneumonia and even, eventually, cancer of the esophagus. Achalasia cardia is rare, but proper diagnosis and treatment are necessary to prevent dangerous complications.

What doctors treat achalasia cardia?

Gastroenterologists are the doctors involved in diagnosing and managing achalasia cardia. Surgeons will be involved if surgical intervention becomes necessary.

Diagnosis

Diagnostic methods help confirm the condition and help doctors decide which treatment method will work best for a particular patient.

Diagnostic methods include the following:

• Upper endoscopy of the GI tract: A tube is used and the inside of the esophagus, stomach, and duodenum are viewed.
• Barium X-ray: A scan is done after swallowing barium. Barium is an opaque substance that helps accentuate internal structures because it shows up on X-rays. Barium helps highlight the digestive organs, their size and their structure.
• Esophageal manometry: This test measures the strength of contraction of the esophagus muscles. This is an important test for swallowing disorders to see how well muscles work to push food down the esophagus.

There are a few options for treating achalasia cardia, which are discussed below:

Medication

Nifedipine or isosorbide are two medicines that can help to relax the LES muscles. However, these may not work for all patients. This is a biochemical method to correct the flawed action of the muscle, and if this fails, the next step is to try a mechanical approach.

Mechanical approaches for treating achalasia cardia are given below:

Pneumatic dilation (PD)

This is when a balloon is attached to an endoscope which is placed down the esophagus. The balloon is then inflated, which functions to open up the LES. The pneumatic dilation approach may work for some patients, but often, the effect may not last, and it may need to be done again in a few years’ time. PD is most effective for patients who have type II achalasia cardia but less so for patients with more severe achalasia cardia, such as those with type III achalasia.

Heller myotomy

Besides PD, Heller myotomy is another procedure that acts to mechanically alter the function of the LES.

A Heller myotomy is done as a laparoscopic surgery that usually includes fundoplication. Fundoplication is the rearrangement and placement of the top part of the stomach over the LES. This is often done as part of the surgery.

• The idea of the fundoplication is to help further reinforce the proper functioning of the LES by reducing the likelihood of GERD.
• GERD is a consequence of loosening the LES muscle. Thus fundoplication is also completed to prevent this complication.
• The myotomy involves the surgeon cutting the LES muscle and part of the stomach muscle to reduce the tightness of the LES.

The Heller myotomy with fundoplication procedure is often effective for patients with achalasia cardia. This is also often the first type of treatment that is recommended for patients once the treatment with medication has failed.

The myotomy, along with fundoplication, is also recommended when achalasia cardia occurs in young children. This is because other methods only work temporarily and often fail to be effective in treating the condition in these young children.

Post-operative care

You may need to remain in the hospital for a few days, and further X-rays may be done to check that the outcome is as expected.

Complications

Complications of the surgery are rare but could include the following problems:

• Inflammation of the esophagus
• Perforation of the esophagus

Peroral endoscopic myotomy (POEM)

This is a method in which the muscles of the LES are made looser by using an intra-oral approach. This is a good alternative to traditional and laparoscopic surgery, where incisions are made through the skin and tissues to access the LES.

• The POEM procedure is carried out through an endoscope rather than the usual surgical methods.
• Surgery is performed but only by way of the endoscope tube.
• POEM seems to work best for cases of severe achalasia where muscles are spastic.

Post-operative care

A patient often needs to remain in the hospital for a few days. Only soft foods and liquids can be consumed for the first 14 days postoperatively.

Complications

Complications of POEM are rare, but there is a risk of patients developing the following problems after the procedure:

• An inflamed esophagus
• Bleeding in the esophagus.
• GERD

GERD is another potential complication because loosening the LES may increase this issue for some patients. The risk of GERD is higher with the POEM than the laparoscopic myotomy.

References:

• Buick, R. G., & Spitz, L. (1985). Achalasia of the cardia in children. Journal of British Surgery, 72(5), 341-343.
• Ghoshal, U. C., Daschakraborty, S. B., & Singh, R. (2012). Pathogenesis of achalasia cardia. World journal of gastroenterology: WJG, 18(24), 3050.

• Pratap, N., Kalapala, R., Darisetty, S., Joshi, N., Ramchandani, M., Banerjee, R., ... & Reddy, D. N. (2011). Achalasia cardia subtyping by high-resolution manometry predicts the therapeutic outcome of pneumatic balloon dilatation. Journal of neurogastroenterology and motility, 17(1), 48.
• Poornachand, V., Kumarasamy, K., Karamath, S. P., Seenivasan, V., Bavanandam, S., & Dheivamani, N. (2018). Achalasia Cardia in a Young Infant. The Indian Journal of Pediatrics, 85, 673-675.
• Ramchandani, M., & Pal, P. (2020). Achalasia Cardia: A Comprehensive Review. Gastroenterology,
• Ramchandani, M., Nageshwar Reddy, D., Nabi, Z., Chavan, R., Bapaye, A., Bhatia, S., ... & Inoue, H. (2018). Management of achalasia cardia: expert consensus statements. Journal of gastroenterology and hepatology, 33(8), 1436-1444.

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