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LECTURE

ON

ACHALASIA

S. RAD

With the cases from his own file

Tabriz University of Medical Sciences


Tabriz-Iran

1 Feb 2009 SR
TECHNIQUE OF EXAMINATION

Apart from clinical manometer no imaging


modality compares to fluoroscopic examination
with spot-filming for diagnosis of Achalasia.

In fact any functional disorder in gastro-intestinal


tract needs to be evaluated studying its state of
being in rest and moving modifications.
Fluoroscopy, an appropriate means to study
movements, can give functional data and is the
only one to be implemented for diagnosis in these
cases.
2 Feb 2009 SR
MECHANISM OF PRODUCTION
Achalasia a negative version of chalasia ( wide open gastric cardia with
facilitated gastro-esophageal reflux ) means non relaxation of the
sphincteric mechanism in the lower esophagus.
Absence of the anatomical sphincter in the lower esophagus is
compensated with the synergic action of multiple elements to play this
role:

The acute angle of the entrance of the lower esophagus into the stomach
(namely angle of His), hypertonic circular muscles of the lower esophagus
by creating high pressure zone in this area, phrenico-esophageal membrane
( Laimer’s) and freely to and fro moving of the esophageal vestibula in
diaphragmatic hiatus surrounded by sling muscles of the diaphragmatic
crura, All are collaborating to close the cardia in resting state with the
added effect of the gastrin content of the stomach or circulating one to
produce tough closure of the cardia to prevent gastro-esophageal reflux.
3 Feb 2009 SR
ETIOLOGY
Cerebral cortex is the dominating commander of the esophageal function.
This is done by psychogenic effect or by cranial neural impact on the
esophagus, specially vague or pneumo-gastric one (No X) via the
ambiguous nucleus of this nerve in the brain as the main factor.
This nervous impulse is effectuated by myenteric plexus (Auerbach) of
the esophagus itself to autonomic movement of the organ.
According to the above-mentioned origins, achalasia may be due to :
-Psychogenic disturbance
-Vagal transmitting defect, such as seen in vagotomy or Chagas disease.
-Lack of myenteric or autonomic nervous plexus of the esophagus itself.

4 Feb 2009 SR
The very first sign of the achalasia is the
apparition of retention of fluid in its lumen which
normally takes no more than 5 or 6 second to
empty, subsequently a fluid level in the
esopghagus is not seen in standing position, where
the gravity should accelerate the stripping
function of the organ.
To notice this phenomenon it is mandatory to start
examination in erect or upright position. This is
just the opposite of esophageal involvement in
scleroderma ( progressive systemic sclerosis)
which demands examination in lying down
position to suppress the gravity action of the
stagnating fluid to notice the peristalsis only.
5 Feb 2009 SR
Air bubble of the stomach is produced by aerophagia or swallowed
air. In the case of achalasia stagnation of the fluid inside esophagus
prevents air to reach the stomach and so, lack of gastric air bubble or
its diminution may be another important sign of the insult.
6 Feb 2009 SR
Achalasia may be seen at the level of the crico-
pharyngeus muscle, called superior achalasia or at the
lower end, the ordinary lower achalasia. In any case it is
produced by non-relaxation of the sphincters, upper one
been a true or anatomical sphinter ( crico-pharyngeus
muscle) and a sphincteric mechanism in lower end or
sometimes anatomical caused by non-relaxation of the
crura sling muscle.
A special type of this disorder may also be seen and
caused by secondary obtruding factors of the cardia in
fact pseudo-achalasia, a justified nomenclature.

7 Feb 2009 SR
Pharyngeal achalasia
8 Feb 2009 SR
Cricopharyngeus or
UES

9 Feb 2009 SR
There are no stripping waves
and inactive peristalsis is
not able to evacuate
esophagus . Tubular
esophagus or Ring A is
located where the muscular
part transforms to the
vestibular region and non-
relaxation of the lower end
of the organ affects this
point . That is why the
lower end of the esophagus
in achalasia appears conical
( Bird’s beak) caused by
contractile state of the
circular muscles.
10 Feb 2009 SR
Conical and
concentric tapering
of the lower
esophagus stands
just at the cardia.

11 Feb 2009 SR
Persistent retention
because of the inactive
stripping waves
despite their force in:
Vigorous achalasia.

12 Feb 2009 SR
Vigorous achalasia.
13 Feb 2009 SR
With previous operation ( Heller type ) there
is usually a diverticulum formation at the
14 cardia.
Feb 2009 SR
Deformity due to the
previous operation.
15 Feb 2009 SR
Before and after operation.
Inefficient operation in advanced cases.
16 Feb 2009 SR
Huge epiphrenic
diverticulum is the rule
in achalasia.
17 Feb 2009 SR
Food retention in epiphrenic diverticulum.
18 Feb 2009 SR
Double epiphrenic
diverticulum.
Sorry for the patient’s
fore-arm inadvertently
overlapping the lower
end of the esophagus!

19 Feb 2009 SR
Huge epiphrenic diverticulum
simulating
Heart filled up with food!

20 Feb 2009 SR
Diverticulum in achalasia simulating lung tumor.
21 Feb 2009 SR
Achalasia demonstrated in
chest CT, only a
morphological evaluation

22 Feb 2009 SR
Fluid level in
the
esophagus.
In CT and
barium
study. Bird’s
beak sign
may be
shown only
in
reformatting
coronal
aspect with
23 Feb 2009
MDCT SR
Achalasia with unusual diverticulum simulating neural
tumor.
24 Feb 2009 SR
CTs of the same patient

25 Feb 2009 SR
Deviation of dilated
esophagus to the right
side:

Men’s socks
appearance

26 Feb 2009 SR
Men’s socks appearance.
27 Feb 2009 SR
No relevant chest x-ray. There are always
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exceptions for the rules!
Feb 2009 SR
Paraffinoma due
to the oil ingestion
in achalasia to
facilitate
swallowing in
some way.

29 Feb 2009 SR
Esophageal wall
seen on the top of
the mediastinal
widening is in
favor of achalasia.

30 Feb 2009 SR
Operated thoracic
transferred stomach
usually presents a
thick wall and
should not be
confused with
achalasia.

31 Feb 2009 SR
Odd pattern of the filled up thoracic stomach caused by
narrowing of the pylorus or tight hiatus not widened
32 duringFeb operation.
2009 SR
Lung abscess simulating cavitating malignancy due to
perforate achalasia. Notice fluid level in the esophagus at
the plain film, best sign for fluid stagnation.
33 Feb 2009 SR
Lung or mediastinal abscess caused by perforated
achalasia.
34 Feb 2009 SR
Lung abscess caused by
repeated aspiration in
achalasia. Notice:
esophageal wall in
mediastinum and
absence of gastric air
bubble.

35 Feb 2009 SR
Pseudo-achalasia due to tumor infiltration of the cardia.
36 Feb 2009 SR
Different
cases of
pseudo-
achalasia.

37 Feb 2009 SR
Pseudo-achalasia diagnosed in plain abdominal
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film.
Feb 2009 SR
Achalasia may occur in
children as well:
One-year-old child

One and half-year-old

39 Feb 2009 SR
Four-year-old

Seven-year-old

40 Feb 2009 SR
Twelve-year-old
child having
trouble since
infancy.

41 Feb 2009 SR
Onset of malignancy
in long standing
achalasia.

Tumor occurrence is almost


always above the cardia

Ninety-year-old patient

42 Feb 2009 SR
Malignancy is located almost always above the cardia.
43 Feb 2009 SR
Conclusion
Achalasia may be guessed by the absence
of the gastric air bubble on the chest x-rays
in clinically suspicious settings. There is no
air-fluid level seen on the plain film of the
normal esophagus and its apparition is in
favor of achalasia in most of the cases with
mediastinal widening. Conical and
concentric tapering of the cardia with
reservation of the normal mucosal pattern
confirms the diagnosis of the achalasia.
44 Feb 2009 SR
THE END

45 Feb 2009 SR