Achalasia Cardia

Achalasia cardia is a motility disorder of esophagus which causes incomplete relaxation of lower esophageal sphincter (LES) with increase in tone and absence of esophageal peristalsis.
It is also termed as esophageal achalasia, esophageal aperistalsis and cardio spasm.
Esophagus is important part of GT tract. It is a muscular tube extending from neck to abdomen. It acts as a connection between throat and stomach. The lower esophageal sphincter is a muscular ring that that closes off esophagus form stomach.
In achalasia cardia, lower esophageal sphincter remains closed or is unable to open during swallowing and hence esophagus is unable to move food into the stomach.
It is a rare condition and occurs in 1 person in 100,000 per year.

Symptoms of achalasia cardia

Inability to swallow.
Regurgitation of food or saliva.
Heart burn and chest pain that comes and goes. Chest pain are often mistaken for a heart attack.
Weight loss.
Vomiting.
In some cases, coughing may occur while lying in horizontal position.

Its exact cause or mechanism is not known till date.
It may be due to loss of nerve cells in esophagus. It is also thought to be related with autoimmune disorder, viral infection or genetic disorder.

It has similar symptoms as of GERD (Gastroesophageal reflux disease), hiatus hernia or psychomotor disturbance. So thorough diagnosis should be done.
Specific test for achalasia cardia is esophageal manometry and barium swallow. Endoscopy of esophagus, duodenum and stomach with or without endoscopic ultrasound is also helpful.
Esophageal manometry measures rhythmic muscular contraction in esophagus while swallowing food, coordination and force exerted by esophageal muscles and how well LES opens or closes while swallowing. It is considered key diagnostic technique in achalasia cardia.
In barium swallow, patient is made to swallow barium solution and its movement through the esophagus is observed through fluoroscopy.

Lifestyle modification like eating food slowly, drinking plenty of water, not eating food near bedtime, sleeping with wedge pillow may be helpful in relieving symptoms.
Pneumatic dilation in which balloon is inserted into esophageal sphincter and then inflated to enlarge sphincter opening is helpful. This stretches the sphincter and helps in better function of esophagus. However, there is risk of tearing of sphincter which may require additional surgery for repair.
The surgical method used are Heller myotomy and peroral endoscopic myotomy (PEOM). The muscle at lower end of esophageal sphincter is cut which allows food to pass easily into stomach. Heller myotomy is effective in about 90 % of patients. however, there is risk of developing GERD later.
After pneumatic dilation or surgery, proton pump inhibitors may be required to inhibit gastric acid secretion and prevent reflux damage and foods that promote reflux like caffeine, chocolate, ketchup and citrus foods should be avoided.
Botox (botulinum toxin A) can be injected directly into esophageal sphincter. It is preferred in patients who are not good candidate for pneumatic dilation or surgery. Its effect is temporary and lasts about 6 months.
Medications which relaxes LES like calcium channel blockers (nifedipine) or nitrates (nitroglycerine) are useful. They have limited treatment effect and severe side effects, so they are rarely preferred.