Treatments For Achalasia
Having achalasia is a condition in which the lining of the throat becomes inflamed and can lead to problems in swallowing. There are a number of treatments available to help patients with this condition. The treatment for achalasia may be as simple as a swallow test, or it may require more advanced procedures such as Endoscopic balloon dilation.
Diagnosis
Despite its rarity, achalasia remains a difficult condition to diagnose. Patients may present with dysphagia, chest pain, and other oesophageal symptoms. The disorder is characterized by loss of peristalsis and insufficient relaxation of the lower esophageal sphincter (LES).
Achalasia is a neurodegenerative motility disorder of the esophagus. The primary etiology is believed to be a selective loss of inhibitory neurons. These neurons release nitric oxide, vasoactive intestinal peptide, and acetylcholine, which interrupt esophageal peristalsis. The resulting obstruction causes esophageal outflow obstruction (EO).
Achalasia is diagnosed by esophageal manometry, endoscopy, and esophageal pressure topography. The latter is a higher-confirmation diagnostic test than conventional manometry.
Achalasia is a life-long disease. Treatment is focused on restoring motility in the esophagus. Treatment methods include surgical myotomy, Botulinum toxin injection to the LES, and pneumatic balloon dilatations. The most effective treatment is Heller myotomy. This surgery divides muscle fibers of the lower esophageal septum. It is a minimally invasive procedure that is performed laparoscopically and results in a faster recovery.
In the absence of surgery, achalasia patients may get temporary relief from medications. However, these reliefs are limited and are often short-lived.
Newer, more advanced endoscopic treatments include Per Oral Endoscopic Myotomy (POEM). POEM is a novel endoscopic procedure designed to treat achalasia. It involves dividing muscle fibers of the lower esophageal segment without surgery. The procedure is currently under study and is reported to provide comparable results to laparoscopic Heller myotomy.
Treatment options
Fortunately, there are treatment options for achalasia that are safe, effective, and minimally invasive. Moreover, they are tailored to the needs of the individual patient. These treatments are palliative and are designed to minimize esophageal stasis and improve the quality of life.
Treatment options for achalasia include surgical myotomy, pneumatic balloon dilatation, and peroral endoscopic myotomy. Surgical myotomy disrupts the lower esophageal sphincter (LES). During this procedure, the surgeon cuts the abnormal muscle spanning the lower esophagus. In some patients, this procedure is accompanied by an antireflux procedure to partially strengthen the LES.
Pneumatic balloon dilatation is a less invasive procedure. The patient is inserted into a thin tube with an uninflated balloon. The balloon is then inflated as the doctor approaches the LES muscle. This technique is usually performed laparoscopically.
The procedure is highly effective for all age groups, especially young men. However, this procedure is often performed in conjunction with an antireflux procedure to strengthen the valve.
Peroral endoscopic myotomy (POEM) is a newer treatment option for achalasia. Developed in Japan, this procedure is a hybrid endoscopic-surgical procedure. POEM is a safe and effective procedure that reduces the need for repeat surgeries. It is gaining in popularity in Asia and other parts of the world but has not yet achieved universal acceptance.
Botulinum toxin A is another treatment option for achalasia. Botulinum toxin A relaxes the LES, making it easier to open. Oral agents are also used to relieve symptoms in patients who are not able to tolerate surgery.
Endoscopic balloon dilation
Using an air-filled cylinder-shaped balloon, a pneumatic dilation technique is believed to disrupt the muscles of the lower esophageal sphincter (LES), causing the LES to stretch proportionately to the balloon’s diameter. The balloon is inflated to 10 psi pressure and held for a period of 30 seconds. The balloon is then deflated and passed through the patient’s mouth and throat.
The lower esophageal sphincter is a ring of muscle fibers that prevent the backflow of food and other material. Achalasia occurs when the LES is too tight and cannot relax during swallowing. A pneumatic dilation technique is an endoscopic treatment for achalasia. It is known to be effective in 70% to 80% of patients.
In this study, 22 patients with achalasia were evaluated endoscopically, clinically, and manometrically. They were also evaluated radiologically. The patients underwent EUS 24 hours after PD. A total of thirteen patients had repeat dilations within the first two years of follow-up. In addition, five patients required further treatment.
Several studies have shown that pneumatic dilation is effective in treating achalasia. However, it is not yet known which factors can predict the outcome of a dilation. This study aimed to define the factors influencing a dilation’s outcome. Specifically, we evaluated the recurrence rate of achalasia and the recurrence rate of symptom recurrence after PD.
Symptom recurrence was higher in younger patients and those with classic achalasia. The 5-year recurrence rate was 28% and the 10-year recurrence rate was 34%. Achalasia recurrence was higher in patients with LOS pressure above 10 mm Hg. The rate of balloon inflation was a critical factor in maintaining the integrity of the LES.
POEM
PERORAL ENDOCRINE MYOTOMIA (POEM) is a new treatment modality for achalasia. It is a minimally invasive, safe procedure that targets the lower esophageal sphincter (LES). Symptoms are relieved by decreasing the resting pressure of the LES, which in turn facilitates the passage of ingested material.
In the current study, the outcomes of POEM were evaluated in 15 consecutive cases of achalasia. The patients had an average follow-up period of 40.1 months. Several clinical and procedural adverse events were reported, but none were serious.
The clinical success rate was 83 percent at 5 years. The mean Eckardt score after the procedure improved from 4.3 to 1.64. The mean PCS and MCS were also significantly better than their preoperative values.
The results of POEM were comparable to those reported in a previous study, which showed a 96% success rate in pediatric achalasia patients. POEM also showed a favorable clinical response in patients who had failed previous achalasia attempts.
POEM is effective in achalasia, but the long-term durability of the procedure is uncertain. In order to understand the long-term efficacy and safety of POEM, future large-scale multicenter studies should be conducted.
Several studies have been performed to evaluate the efficacy and safety of POEM in achalasia patients. These studies included patients who had previous treatments such as laparoscopic Heller’s myotomy (LHM) and balloon dilation (BT). The results of these studies showed that POEM had an effect on achalasia patients, but no increased incidence of adverse events was found.
Nitrates and calcium channel blockers
Currently, the most common agents for LES pressure reduction are calcium channel blockers and beta-adrenergic agonists. Other less common agents include anticholinergics and nitrates. These drugs are effective at reducing LES pressure, but they are rarely effective at long-term symptom relief. In addition, they have side effects that limit their use.
In addition to conventional therapy, there are non-conventional treatments that are used to treat achalasia. These include endoscopic procedures and surgical treatments. These procedures are evaluated for their safety and efficacy and are only used when they are appropriate.
One of the main reasons for using nitrates is their ability to relax the esophageal smooth muscle. Nitrates work by activating guanylate cyclase. Guanylate cyclase is a protein kinase that increases cGMP synthesis from guanosine triphosphate. The synthesis of c-GMP regulates cytoplasmic free calcium concentration. Nitrates increase cytosolic NO concentration and induce calcium extrusion in smooth muscle cells.
Although it is not recommended for routine use in the megaesophagus, nitrates may have additive effects when used to treat dysphagia. Nitrates act on smooth muscle through an endothelium-independent mechanism. Nitrates are available as tablets. They should be taken before meals. They have a peak effect between 20 and 45 minutes after administration.
In addition to nitrates, sildenafil has also been proposed as an alternative pharmacologic agent for achalasia. Sildenafil is a 5-phosphodiesterase inhibitor that lowers the propulsive forces in the esophagus. It also inhibits the breakdown of cGMP.
X-ray and barium swallow test
X-ray and barium swallow tests for achalasia can detect abnormalities in the upper gastrointestinal tract. They can be performed in the X-ray room or as an outpatient test. They can reveal esophageal dilation, dilation of the junction, or esophageal stricture. They can also detect muscle or nerve problems. The test may also be used to detect polyps, which can be a precursor to cancer.
The test is a relatively safe procedure. It may be performed as an outpatient and is relatively inexpensive. However, risks can vary depending on the medical condition and the number of x-ray treatments performed. It is important to ask your doctor about these risks as they apply to you.
The test requires patients to lie on an X-ray table. Barium is ingested, and the X-ray table is tilted to view the lower esophagus. The X-ray table can also be tilted back, allowing the radiologist to view the colon. The test is typically performed in less than half an hour.
Before the test, the patient should eat a low-fiber diet for 2 to 3 days, avoid eating after midnight and stop smoking. It is also important to remove any jewelry that may interfere with the test.
Barium can easily coat the stomach, pharynx, and bowels. The test may reveal an esophageal stricture, a condition that can cause severe symptoms. Inflammation of an esophageal stricture can lead to bleeding and scarring.
Health Sources:
Health A to Z. (n.d.). HSE.ie. https://www2.hse.ie/az/
Directory Health Topics. (n.d.). https://www.healthline.com/directory/topics
Health A-Z. (2022, April 26). Verywell Health. https://www.verywellhealth.com/health-a-z-4014770
Harvard Health. (2015, November 17). Health A to Z. https://www.health.harvard.edu/health-a-to-z
Health Conditions A-Z Sitemap. (n.d.). EverydayHealth.com. https://www.everydayhealth.com/conditions/
