Achalasia (cont.)
How is achalasia treated?
Treatments for achalasia include oral medications,
dilation or stretching of the lower esophageal sphincter (dilation), surgery to
cut the sphincter (esophagomyotomy), and the injection of botulinum toxin
(Botox) into the
sphincter. All four treatments reduce the pressure within the lower esophageal
sphincter to allow easier passage of food from the esophagus into the stomach.
Oral medications
Oral medications that help to relax the lower esophageal sphincter include
groups of drugs called nitrates, e.g., isosorbide dinitrate (Isordil) and
calcium-channel blockers, e.g., nifedipine (Procardia) and verapamil (Calan).
Although some patients with achalasia, particularly early in the disease, have
improvement of symptoms with medications, most do not. By themselves, oral
medications are likely to provide only short-term and not long-term relief of
the symptoms of achalasia, and many patients experience side-effects from the
medications.
Dilation
The lower esophageal sphincter
also may be treated directly by forceful dilation. Dilation of the lower
esophageal sphincter is done by having the patient swallow a tube with a balloon
on the end. The balloon is placed across the lower sphincter with the help of
x-ray, and the balloon is blown up suddenly. The goal is to stretch--actually to
tear--the sphincter. The success of forceful dilation has been reported to be
between 60 and 95%. Patients in whom dilation is not successful can undergo
further dilations, but the rate of success decreases with each additional
dilation. If dilation is not successful, the sphincter may still be treated
surgically. The main complication of forceful dilation is rupture of the
esophagus, which occurs 5% of the time. Half of the ruptures heal without
surgery, though patients with rupture who do not require surgery still must be
followed closely and treated with antibiotics. The other half of ruptures
require surgery. (Although surgery carries additional risk for the patient,
surgery can repair the rupture as well as permanently treat the achalasia with
esophagomyotomy.) Death following forceful dilation is rare. Dilation is fast,
inexpensive compared with surgery, and requires only a short hospital stay.
Esophagomyotomy
The sphincter also can be cut surgically, a procedure called esophagomyotomy.
The surgery can be done using a large abdominal incision or laparoscopically through
small punctures in the abdomen. In general, the laparoscopic
approach is used with uncomplicated achalasia. Alternatively, the surgery
can be done with a large incision or laparoscopically
through the chest. Esophagomyotomy is more successful than forceful dilation, probably
because the pressure in the lower sphincter is reduced to a greater extent
and more reliably; 80-90% of patients have good results. With
prolonged follow-up, however, some patients develop recurrent dysphagia. Thus, esophagomyotomy
does not guarantee a permanent cure. The most important side effect from the
more reliable and greater reduction in pressure with esophagomyotomy, is reflux of acid
(gastroesophageal reflux disease or GERD). In order to prevent this, the
esophagomyotomy may be modified so that it doesn't completely cut the sphincter
or the esophagomyotomy may be combined with anti-reflux surgery
(fundoplication). Whichever surgical procedure is done, some physicians
recommend life-long treatment with oral medications for acid reflux. Others
recommend 24 hour esophageal acid testing with lifelong medication only if acid
reflux is found.
Botulinum toxin
The newest treatment for achalasia
is the endoscopic injection of botulinum
toxin
into the lower sphincter to weaken it. Injection is fast, nonsurgical, and
requires no hospitalization. Treatment with botulinum toxin is safe, but the
effects on the sphincter often last only for months, and additional injections
with botulinum toxin may be necessary. Injection is a good option for patients
who are very elderly or are at high risk for surgery, e.g., patients with severe
heart or lung disease. It also allows patients who have lost substantial weight
to eat and improve their nutritional status prior to "permanent" treatment with
surgery. This may reduce post-surgical complications.
- Achalasia is a rare disease of the muscle of the
lower esophageal body and the lower esophageal sphincter.
- The cause of achalasia is unknown; however, there is
degeneration of the esophageal muscle and, more importantly, the nerves that
control the muscle.
- Common symptoms of achalasia include difficulty
swallowing, chest pain, and regurgitation of food and liquid.
- Complications of achalasia include lung problems and
loss of weight.
- Achalasia may increase the risk of cancer of the
esophagus, but this is not clear.
- Achalasia can be diagnosed by x-ray, endoscopy, or
esophageal manometry.
- Treatments for achalasia include oral medications, dilation or stretching of
the esophagus, surgery, and injection of muscle-relaxing medicines (botulinum
toxin) directly into the esophagus.
Last Editorial Review: 2/11/2005
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