What happens to the esophagus
In the wall of the esophagus there is a nerve plexus that coordinates its contractions and the timely opening of the lower sphincter. With achalasia, these neurons gradually die, and coordinated work is disrupted: the sphincter remains tightly closed, and the body of the esophagus does not push the food bolus. The contents accumulate over the narrowed area, the esophagus expands, sometimes significantly, and takes on a characteristic shape on an x-ray. The process develops slowly, so a person takes a long time to adapt: he drinks food, eats standing, arches his neck, limits solid food.
- Death of nerve cells in the wall of the esophagus
- The lower sphincter does not relax when swallowing
- No promotional cuts
- Gradual expansion of the esophagus
- Retention of food above the sphincter
Symptoms
The leading symptom is difficulty swallowing, and often the fluid passes worse at first or difficulties arise intermittently, which distinguishes achalasia from tumor narrowing. The second characteristic symptom is regurgitation of undigested food without a sour taste, sometimes during sleep, with a night cough and the risk of the contents getting into the respiratory tract. Many people report pain or pressure behind the sternum, which is mistaken for heart pain. Weight gradually decreases. People unconsciously develop techniques: they wash down food with large sips of water, raise their arms, straighten their back to push food through.
- Difficulty swallowing solid and liquid foods
- Regurgitation of undigested food
- Night cough and choking
- Pain and pressure behind the sternum
- Weight loss
- Techniques to help push food through
How is it different from reflux and tumor?
With reflux disease, the contents are sour, there is heartburn, symptoms worsen while lying down and after a heavy meal, and swallowing is usually not impaired. With achalasia, undigested food without acid returns, and heartburn, if there was one, is often not relieved by standard medications. Tumor narrowing is characterized by rapid progression: over weeks or months, the passage of first hard, then soft food worsens, weight quickly drops, and older people get sick more often. That is why, if there are complaints of difficulty swallowing, gastroscopy is mandatory - it allows you to exclude a tumor.
- Reflux - acidic contents and heartburn
- Achalasia - undigested food without acid
- Tumor—rapid deterioration and weight loss
- Achalasia develops over years
- Gastroscopy is mandatory in all cases
Diagnostics
X-ray of the esophagus with contrast shows a dilated esophagus with a smooth narrowing in the lower section and contrast delay, which immediately allows one to suspect the diagnosis. Gastroscopy is necessary, but not so much for confirmation as to exclude tumors, strictures and esophagitis: with achalasia, the endoscope usually passes into the stomach with slight resistance. The gold standard is esophageal manometry, which measures pressure and contraction patterns; it also allows you to determine the type of disease and more accurately choose treatment. Computed tomography is prescribed if there is a suspicion of a process compressing the esophagus from the outside.
- X-ray of the esophagus with contrast
- Gastroscopy to exclude a tumor
- Esophageal manometry
- Computed tomography according to indications
- Weight and nutrition assessment
Treatment
It is impossible to cure the nervous system of the esophagus, so all methods are aimed at reducing resistance in the area of the lower sphincter. Balloon dilatation stretches the narrowed area, the procedure is effective, but often requires repetition. Heller myotomy is an operation in which the muscle fibers of the sphincter are cut, usually laparoscopically and in combination with antireflux plasty; the result is permanent. There is also an endoscopic version of myotomy through the mouth. Botulinum toxin injections provide a temporary effect and are used in elderly and debilitated patients. Nutrition is adjusted: eat slowly, in small portions, chew thoroughly, do not eat before bed.
- Balloon dilatation of the lower sphincter
- Laparoscopic Heller myotomy
- Endoscopic myotomy
- Botulinum toxin injections for contraindications to surgery
- Small meals, eating slowly, chewing thoroughly
- Do not eat 3 hours before bedtime and sleep with the head of the bed elevated
- Observation by a gastroenterologist after treatment