• It develops as a result of degeneration of ganglia in the myenteric (Auerbach) plexus.
Ganglion degeneration may be associated with a latent viral infection (HSV type 1).
• Trypanosoma Cruzi can cause Chagas disease, which is similar to achalasia, by involving the myenteric plexuses.
• Gastric tumors located in the cardia or tumors of the lower end of the esophagus may also create a clinical picture that mimics achalasia. For this reason, endoscopy is performed when the initial diagnosis of achalasia is made.
• Achalasia-like picture secondary to Chagas disease or tumors is defined as pseudoachalasia or secondary achalasia.
Clinic
• Although it can be seen at any age, it is more common between the ages of 25-60.• The most important symptom is dysphagia and it occurs against both solid and liquid foods from the beginning. Dysphagia can progress over months and years.
• Post-meal substernal pain and regurgitation may occur, vomiting of undigested food is typical in advanced cases.
• Cough, aspiration and pulmonary problems may occur due to regurgitation.
• Chest pain is more common in the early stages of the disease; pain may decrease and dysphagia may increase in the late period.
• The risk of esophageal squamous cell cancer increases in patients.
Diagnosis
• The first test to be done is barium esophageal graphy. Barium graph findings;Smooth-edged constriction at the lower end of the esophagus (bird's beak)
Enlargement proximal to the stricture (megaesophagus, sigmoid esophagus)
• Loss of gastric air chamber and air-fluid level in the esophagus can be seen on direct radiograph.
• Endoscopy is absolutely necessary for differential diagnosis and to rule out a possible malignant disease.
• Definitive diagnosis can be made by esophageal manometry. Manometric findings;
Loss of peristalsis in the distal esophagus
Inability to relax or incomplete relaxation in LES
increase in LES tone
Treatment
• Medical treatment: Calcium channel blockers (nifedipine) or nitrates (isosorbide dinitrate) can be administered.• Dilatation treatment: Balloon dilatation is the most commonly preferred method in practice and its success rate is close to surgical treatment.
• Endoscopic myotomy (POEM): It is defined as peroral endoscopic myotomy.
• Injection therapy: Botulismus toxin is injected endoscopically into the lower end of the esophagus, preventing the release of acetylcholine and paralyzing the lower esophageal sphincter muscles.
• Surgical treatment: It is performed with laparoscopic or classical methods (Heller myotomy+Nissen funduplication) in patients who do not respond to other methods. It is the most effective treatment method.