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Achalasia

Achalasia is a specific neuro-gastroenterological condition which leads to loss of the interconnections between the nerves cells within the complex meshwork of n erve fibres which co-ordinate the swallow (myenteric plexi). This leads to symptoms of difficulty swallowing both swallows and liquids. This disco-ordination is often associated with episodes of chest pain and food regurgitation, since food becomes trapped in the non function oesophagus is unable to make it’s way into the stomach. Neither the oesophageal body nor the lower oesophageal sphincter function normally. The lower oesophageal sphincter fails to relax, the oesophageal body fails to contract in a way which enables swallowing to be effective. As a consequence considerable food debris can accumulate within the oesophagus, leading to regurgitation and a risk of aspiration of food into the airway.

Achalasia can be sub-classified into a number of different types I, 2 and 3. In type 1 there is no effective contraction within the gullet at all. In type 2 there is a simultaneous oesophageal contraction, rather than a peristaltic one (ie a wave of contraction that moves down the gullet over time, as occurs in normal swallowing), however there is nor relaxation of the lower oesophageal sphincter, in type 3 the gullet develops persistent spasm like contraction on swallowing, which may be painful. In all three types food and debris accumulate in the oesophagus. Treatments vary. Surgical or endoscopic myotomy, where the lower oesophageal sphincter is cut by an operation tends to yield the best results, particularly in type 2 disease, however it also has the highest risks of complication (bleeding, perforation amongst others). Balloon dilation has generally less good results but can be very effective and has long-term benefits, it still has a significant risk of complications (oesophageal bleeding and perforation). Injection of Botulinum toxin (botox) into the lower oesophageal sphincter has the lowest risk of complication but also tends to have the least good long-term benefits and often requires repeat injection. The decision to choose a particular therapy is based on the type of achalasia a patient has and the clinical context of the patient. For example a young fit patient with type 2 achalasia might consider surgical intervention first, whereas her 95 year old grandfather might be best having botulinum toxin on the grounds that he is unlikely to be concerned about benefits which may accrue in 5 or 10 years.

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