Esophageal achalasia

Česká verzia

Authors: E. Veseliny; T. Hildebrand; P. Jarčuška; M. Zakuciová
Authors place of work: I. interná klinika Lekárskej fakulty UPJŠ a FNsP, Košice, Slovenská republika, prednosta prof. MUDr. Ivica Lazúrová, Ph. D.
Published in the journal: Vnitř Lék 2005; 51(6): 704-713
Category: Reviews

Summary

Achalasia is a well-recognized primary esophageal motor disorder of unknown etiology. It is characterized by incomplete lower esophageal sphincter (LES) relaxation and aperistalsis of the esophageal body. These abnormalities are thought to result from frequently observed neuropathic changes involving a loss of inhibitory ganglionic cells of myenteric plexus in the LES and in the esophageal body. The pathogenesis of idiopathic achalasia is unknown. Available data suggest hereditary, degenerative, autoimmune, and infectious factors as possible causes for achalasia, the latter two being the most commonly accepted. The diagnosis of achalasia should be suspected in anyone complaining of dysphagia for solids and liquids with regurgitation of food and saliva. The clinical suspicion should be confirmed by a barium esophagram showing smooth tapering of the distal esophagus leading to the closed LES, resembling a „bird’s beak“. Esophageal manometry establishes the diagnosis showing insufficient LES relaxation and esophageal aperistalsis. All patients should undergo upper endoscopy to exclude pseudoachalasia. Although there is no cure for achalasia, the goal of treatment should be relief of patient symptoms and improved esophageal emptying. The two most effective treatment options are graded pneumatic dilation and surgical myotomy. For patients who are at high risk for pneumatic dilation or surgery, endoscopic injection of the LES with botulinum toxin may be acceptable alternative.

Key words:
achalasia – pneumatic dilation – Heller myotomy – botulinum toxin

Zdroje

1. Cash BD, Wong RK. Historical perspective of achalasia. Gastrointest Endosc Clin N Am 2001; 11: 221–233.

2. Vaezi MF, Richter JE. Diagnosis and management of achalasia. Practice guidelines. Am J Gastroenterol 1999; 94: 3406–3412.

3. Mayberry JF. Epidemiology and demographics of achalasia. Gastrointest Endosc Clin N Am 2001; 11: 235–247.

4. Kahrilas PJ. Esophageal Motility Disorders: Pathogenesis Diagnosis and Treatment. In: Champion MC, Orr WC. Evolving Concepts in Gastrointestinal Motility. Oxford: Blackwell Science Ltd. 1996: 15–45.

5. De Giorgio R, Di Simone MP, Stanghellini V et al. Esophageal and gastric nitric oxide synthesizing innervation in primary achalasia. Am J Gastroenterol 1999; 94: 2357–2362.

6. Paterson WG. Etiology and pathogenesis of achalasia. Gastrointest Endosc Clin N Am 2001; 11: 249–265.

7. Spechler SJ. AGA technical review on treatment of patients with dysphagia caused by benign disorders of the distal esophagus. Gastroenterology 1999; 117: 233–254.

8. Robertson CS, Martin BAB, Atkinson M. Varicella-zoster virus DNA in the oesophageal myenteric plexus in achalasia. Gut 1993; 34: 299–302.

9. Jones DB, Mayberry JF, Rhodes J et al. Preliminary report of an association between measles virus and achalasia. J Clin Pathol 1983; 36: 655–657.

10. Birgisson S, Galinski MS, Goldblum JR et al. Achalasia is not associated with measles or known herpes and human papilloma viruses. Dig Dis Sci 1997; 42: 300–306.

11. Verne GN, Sallustio JE, Eaker EY. Anti-myenteric neuronal antibodies in patients with achalasia. A prospective study. Dig Dis Sci 1997; 42: 307–313.

12. Verne NG, Hahn AB, Pineau BC et al. Association of HLA-DR and -DQ alleles with idiopathic achalasia. Gastroenterology 1999; 117: 26–31.

13. De Oliveira RB, Rezende Filho J, Dantas RO et al. The spectrum of esophageal motor disorders in Chagas disease. Am J Gastroenterol 1995; 90: 1119–1124.

14. Goin JC, Sterin–Borda L, Bilder CR et al. Functional implications of circulating muscarinic cholinergic receptor autoantibodies in chagasic patients with achalasia. Gastroenterology 1999; 117: 798–805.

15. Deghaide NHS, Dantas RO, Donadi EA. HLA class I and II profiles of patients presenting with Chagas’ disease. Dig Dis Sci 1998; 43: 246–252.

16. Bettarello A, Pinotti HW. Oesophageal involvement in Chagas disease. Clin Gastroenterol 1976; 5: 103–117.

17. Kahrilas PJ, Kishk SM, Helm JF et al. Comparison of pseudoachalasia and achalasia. Am J Med 1987; 82: 439–446.

18. Ter RB, Govil YK, Leite L et al. Adenosquamous carcinoma in Barret’s esophagus presenting as pseudoachalasia. Gut 1999; 94: 268–270.

19. D’Alteroche L, Oung C, Fourquet F et al. Evolution of clinical and radiologic features at diagnosis of achalasia during a 19 year period in central France. Eur J Gastroenterol Hepatol 2001; 13: 121–126.

20. Hildebrand T Poruchy motility pažeráka, s. 9–36. In: Bátovský M, Hildebrand T, Vavrečka A et al. Poruchy gastrointestinálnej motility a prokinetiká, Janssen-Cilag, Bratislava, 1999, 149 s.

21. Eckardt VF. Clinical presentation and complication of achalasia. Gastrointest Endosc Clin N Am 2001; 11: 281–292.

22. Eckardt VF, Stauf B, Bernhard G. Chest pain in achalasia: Patient characteristics and clinical course. Gastroenterology 1999; 116: 1300–1304.

23. Gonlachanvit S, Fisher RS, Parkman HP. Diagnostic modalities for achalasia. Gastrointest Endosc Clin N Am 2001; 11: 293–309.

24. Burke CA, Achkar E, Falk GW. Effect of pneumatic dilation on gastroesophageal reflux in achalasia. Dig Dis Sci 1997; 42: 998–1002.

25. Dunaway PM, Wong RKH. Risk and surveillance intervals for squamous cell carcinoma in achalasia. Gastrointestin Endosc Clin N Am 2001; 11: 425–433.

26. Brucher BL, Stein HJ, Bartels H et al. Achalasia and esophageal cancer: incidence, prevalence and prognosis. World J Surg 2001; 25: 745–749.

27. Spiess AE, Kahrilas PJ. Treating achalasia. From whalebone to laparoscope. JAMA 1998; 280: 638–642.

28. Kaščák M. Achalázia. Motilita. Bratislava: Janssen-Cilag 1998.

29. Ott DJ, Hodge RG, Chen MY et al. Achalasia associated with esophageal diverticula: Prevalence and potential complitations. J Clin Gastroenterol 1994; 18: 343–348.

30. Evander A, Little AG, Ferguson MK et al. Diverticula of the mid- and lower esophagus: Pathogenesis and surgical management. World J Surg 1986; 10: 820–828.

31. Ott DJ, Richter JE, Chen YM et al. Esophageal radiography and manometry: Correlation in 172 patients with dysphagia. Am J Roentgenol 1987; 149: 307–311.

32. Schima W, Ryan JM, Harisinghani M et al. Radiographic detection of achalasia: Diagnostic accuracyof videofluoroscopy. Clin Radiol 1998; 53: 372–375.

33. Birgisson S, Richter JE. Achalasia: What’s new in diagnosis and treatment? Dig Dis 1997; 15: 1–27.

34. Spechler SJ. Clinical manifestations and diagnosis of achalasia. UpToDate, version 9.3, 2002, May 10.

35. Sanderson DR, Ellis FH, Schlegel JF. Syndrome of vigorous achalasia. Clinical and physiologic observations. Dis Chest 1967; 52: 508–517.

36. Goldenberg SP, Burrel M, Fette GG et al. Classic and vigorous achalasia: a comparison of manometric, radiographic and clinical findings. Gastroenterology 1991; 101: 743–748.

37. Goldblum JR, Rice TW, Richter JL. Histopathologic features in esophagomyotomy specimens from patients with achalasia. Gastroenterology 1996; 111: 648–654.

38. Camacho–Lobato L, Katz PO, Eveland J et al. Vigorous achalasia: original description requires minor change. J Clin Gastroenterol 2001; 33: 375–377.

39. Tracey JP, Traube M. Difficulties in the diagnosis of pseudoachalasia. Am J Gastroenterol 1994; 89: 2014–2018.

40. Goldenberg SP, Vos C, Burrel M et al. Achalasia and hiatal hernia. Dig Dis Sci 1992; 37: 528–531.

41. Koshy SS, Nostrant TT Patophysiology and endoscopic/balloon treatment of esophageal motility disorders. Surgery of the esophagus. Surgical Clinics of North America 1997; 77: 971–992.

42. Prasek J, Hep A, Dolina J et al. Dynamic esophageal scintigraphy in patients with achalasia. Nucl Med Rev Cent East Eur 2000; 3: 57–60.

43. Van Dam J, Falk GW, Sivak MV et al. Endosonographic evaluation of the patient with achalasia: Appearance of the esophagus using the echoendoscope. Endoscopy 1995; 27: 185–190.

44. Annese V, Bassoti G, Coccia G et al. Comparison of two different formulations of botulinum toxin A for

the treatment of esophageal achalasia. Aliment Pharmacol Ther 1999; 13: 1347–1350.

45. Hoogerwerf WA, Pasricha PJ. Pneumatic dilation and botulinum toxin injection for achalasia. UpToDate, version 9.3, 2002, February 15.

46. Martínek J, Široký M, Plottová Z et al. Treatment of patients with achalasia with botulinum toxin: a multicenter prospective cohort study. Dis Esophagus 2003; 16: 204–209.

47. Hep A, Dolina J, Plottova Z et al. Is the complex therapy of achalasia by application of botulotoxin in combination with balloon dilatation a prospective approach? Bratisl Lek Listy 2000; 8: 433–437.

48. Hep A, Dolina J, Dite P et al. Restoration of propulsive peristalsis of the esophagus in achalasia. Hepatogastroenterology 2000; 47: 1203–1204.

49. Kadakia SC, Wong RKH. Pneumatic balloon dilation for esophageal achalasia. Gastrointest Endosc Clin N Am 2001; 11: 325–345.

50. Ali A, Pellegrini CA. Laparoscopic myotomy. Technique and efficacy in treating achalasia. Gastrointest Endosc Clin N Am 2001; 11: 347–357.

51. Vaezi MF, Richter JE. Current therapies for achalasia: Comparison and efficacy. J Clin Gastroenterol 1998; 27: 21–35.

52. Prakash C, Clouse RE. Esophageal motor disorders. Current opinion in gastroenterology 2002; 18: 454–463.

53. Clemente G, D’Ugo D, Granone P et al. Intraoperative esophageal manometry in surgical treatment of achalasia: A reappraisal. Hepatogastroenterology 1996; 43: 1532.

54. Lovecek M, Gryga A, Herman J et al. Peroperative diagnostic methods during esophageal achalasia surgery (Initial experience). Rozhl Chir 2003; 82: 566–569.

55. Richter JE Comparison and cost analysis of different treatment strategies in achalasia. Gastrointest Endosc Clin N Am 2001; 11: 359–369.