What is Achalasia?
Achalasia is a condition in which the ability and function of the esophagus as a driver of food or drink entering from the mouth to the stomach is lost.
This health disorder is very rare, but can be experienced by anyone, children and older persons as well as men and women.
What is esophagus?
Esophageal is a term for the esophagus taken from Greek.
The esophagus is a muscular tube connecting the throat and stomach in vertebrates.
The main function of this esophagus is to help so that food and drinks that enter through the mouth can be pushed into the stomach perfectly.
Meanwhile, when achalasia occurs, the lower esophageal sphincter or LES (lower esophageal sphincter) remains in a closed condition in the swallowing process.
The lower esophageal sphincter itself is a valve that is at the end of the esophagus, which, if the condition is closed when a person swallows, then automatically food will accumulate unable to enter the stomach.
This is what then triggers various symptomatic conditions ranging from food that is not digested perfectly, vomiting food that cannot enter the stomach, heartburn, chest pain, until weight loss is quite drastic.
Achalasia is a condition when the esophagus loses its function as a pusher for food that enters the mouth to reach the stomach.
Facts about achalasia
- Achalasia is classified as a rare health disorder with an estimated case of 1:100,000 per year, but in Indonesia itself there has not been found a clear prevalence.
- According to a report from the Cleveland Clinic, every year in the United States, there are approximately 3,000 people who experience achalasia where the majority of sufferers are older persons.
- Achalasia can occur regardless of gender, race or age, but a study over the past 16 years in the United States showed that the average achalasia patient was under 65 years old with racial minorities.
- Outside the United States, achalasia cases per year are only about 0.1 to 1 per 100,000 people.
- Achalasia is more at risk experienced by people aged between 30-60 years, while found only 2-5% of achalasia cases occur in children aged 16 years and under.
Types of Achalasia
Achalasia is divided into three types of conditions, according to the manometric pattern, namely
In type I achalasia, the condition is characterized by impaired relaxation of the esophagus.
Not only that, in this type of achalasia is also the esophagus dilated with very minimal pressure.
In type II achalasia, the main sign of this condition is that the entire esophagus is under pressure.
But for type II conditions, the prognosis is known to be the best because the possibility of being effectively treated with therapy in the form of LHM (Laparoscopic Heller Myotomy) or PD (Pneumatic Dilatation) is greater than types I and III.
In type III achalasia, it focuses on the part of the distal esophagus that undergoes spastic contractions.
And if type II achalasia is still possible to treat with certain therapies, it is known that type III achalasia is associated with a fairly poor response to treatment.
Achalasia is classified into three types, type I, II and III where type II is more likely to be treated with pneumatic dilatation or laparoscopic heller myotomy than other types of achalasia.
Causes of Achalasia
The reason why the esophageal nerve cells don’t function properly so that the esophagus fails to carry food to the stomach is not clearly known in the condition of achalasia.
When the esophageal nerve cells experience a decrease in function, the muscles lining the esophagus do not work normally and the LES or lower esophageal sphincter does not function.
In the process of swallowing food to run smoothly, the LES needs to be in a relaxed state so that food that enters from the mouth and is swallowed can go straight to the stomach.
When food from the esophagus moves towards the stomach, normally the end of the esophagus closes when the LES muscle contracts.
In the case of achalasia, the LES is not in a relaxed state and instead contracts continuously so that food, drink and saliva cannot be swallowed completely.
As a result, accumulation of food and drink occurs in the esophagus.
Even so, there are several suspected factors that can increase the risk of achalasia in a person, namely
- Genetic predisposition (usually achalasia can be passed on by parents with this disorder to their children)
- Certain viral infections.
- Immune disorders or autoimmune diseases.
The main cause of achalasia is still not clearly known, but it is suspected that achalasia may occur due to immune system disorders, heredity/genetic factors, or certain viral infections.
Symptoms of Achalasia
Achalasia is not a health problem that occurs every day or two, because the following symptoms can be experienced for months to years.
- Dysphagia or difficulty swallowing
- Pain in the chest
- Vomiting due to accumulation of food / drink in the esophagus
- Heartburn (feeling a hot, burning and sore sensation in the chest)
- Hard to burp
- Feels full in the throat and feels like there is a lump in the area
- Weight has decreased
- Frequent hiccups
- Throat like constricted
However, people with dysphagia or difficulty swallowing are not necessary and do not always suffer from achalasia.
Dysphagia sufferers generally do not have serious disorders or disorders of their esophagus.
Patients with symptoms of achalasia with difficulty swallowing at first usually don’t really care about it and will only check their condition to the doctor if the symptoms have developed more seriously.
When experiencing symptoms of difficulty swallowing, sufferers just try to overcome it themselves by eating more slowly.
Or, the patient will try to elevate the neck in order to reduce food buildup in the esophagus.
The main symptom of achalasia is dysphagia or difficulty swallowing, but this condition can also be accompanied by other complaints, such as chest pain, coughing, hiccups, difficulty belching, and vomiting.
When the symptoms of difficulty swallowing accompanied by other complaints begin to be felt, it is better to see a doctor immediately to confirm whether the symptoms lead to achalasia.
Below are several diagnostic methods that are generally used by doctors to confirm the diagnosis.
Barium swallow examination is one of the most common screening or scanning methods used by doctors in diagnosing achalasia.
When the doctor takes pictures through an X-ray process, the patient is asked to swallow a thick barium solution.
This barium will clarify the condition of the esophagus as well as the lower esophageal sphincter.
With this examination, the doctor will be able to find out the end of the esophagus and contraction activity in that area.
Endoscopy is one of the diagnostic methods used by doctors to detect the inside of the esophagus, stomach, and also the lower esophageal sphincter.
This method is applied by doctors by inserting a thin, flexible tube equipped with a camera.
Endoscopy is not only useful in detecting achalasia, but can also be used in detecting other medical conditions that have similar symptoms to achalasia, such as cancer of the upper abdomen.
Endoscopy can also be relied upon by doctors in detecting conditions from fungal infections to inflammation of the patient’s esophagus.
If there is suspicion of stomach cancer, then in this endoscopy process, there is a possibility that the doctor will also apply the biopsy method (taking tissue samples) to find cancer cells at the bottom of the esophagus.
The biopsy procedure that is applied during the endoscopy process is classified as safe. Even for those who are worried, two examination procedures at the same time will not be painful.
Chest x-rays can also be used by doctors to check for esophageal dilation
Even with a special X-ray of the chest will help the doctor find out if there is air in the stomach or not.
However, this chest X-ray is only a complementary test and not a core diagnostic test that can directly confirm achalasia.
The esophagus can experience pressure changes due to contractions of the muscles that line it, and to measure these pressure changes, manometry is needed.
This test is performed by a doctor using a thin tube that is inserted into the mouth or nose which can then be penetrated into the esophagus.
For the best results, the doctor will usually ask the patient before taking this test not to eat and drink for 8 hours before the test takes place.
After being at the examination site and the tube has been installed, the patient will be given a sip of water to swallow.
Esophageal manometry in the process of diagnosing achalasia can detect various forms of disorders associated with achalasia.
The disorder in question is the LES which has high pressure when it is relaxed, the LES cannot relax and continues to contract during the swallowing process, and the absence of peristaltic contractions in the lower esophagus.
Examinations that are generally performed by doctors to confirm achalasia include barium swallow, endoscopy, esophageal manometry and X-rays/chest X-rays.
Treatment of Achalasia
In dealing with achalasia, methods of administering drugs, dilation of the esophagus, and surgery are the most common for patients to get.
To relax the contracting LES and failing to relax after swallowing, medications such as calcium channel blockers and nitrates are most commonly needed by achalasia patients.
This drug comes in the form of a pill which is sufficient to be placed under the tongue for about 10-30 minutes before each patient eats.
But getting here, the use of calcium channel blockers seems to be no longer being carried out considering the safety of its users.
The method of treating achalasia with balloon dilatation is a method to widen the esophagus/esophagus.
A balloon-like device will be inserted until the lower esophageal sphincter or LES is deflated.
The process of placing this device will be very carefully carried out by a doctor using an X-ray machine.
If the position is correct, the doctor will inflate the balloon to make the swallowing process more effective.
Approximately 60% of achalasia sufferers who are treated with this method experience symptom relief after about 1 year and 25% of achalasia sufferers with this method experience symptom relief after 5 years.
Even though it is classified as effective, it is better for people with achalasia before taking this medical procedure to consult all the side effects with a doctor.
Because about 15% of achalasia patients treated with this method experience fever and serious chest pain as a result.
Botulinum Toxin Injection
Handling achalasia with this method is an alternative for achalasia patients who cannot undergo balloon dilatation procedures due to unfavorable health conditions.
In this procedure, the doctor will use an endoscope to inject Botox directly into the LES to open and relax it.
The success rate of this treatment method in relieving symptoms is 65-90% with effects that last approximately 3 months to 1 year.
So if the symptoms reappear, the patient needs to come back to the doctor to get an additional injection.
For achalasia sufferers who are quite severe and achalasia sufferers who are aged 50 years and over, this method of treatment is most recommended.
Myotomy is a surgical procedure by cutting the LES muscle fibers where the most common surgical technique is Heller myotomy with a success rate of 70-90%.
Meanwhile, there is also a peroral endoscopy myotomy procedure performed by doctors with the aim of cutting the LES by inserting an endoscope through the mouth into the esophagus.
Treatment steps for achalasia are generally in the form of drugs, dilation of the esophagus with the balloon dilation method, botulinum toxin injection, or surgery (myotomy) depending on the severity of the patient's condition.
Complications of Achalasia
Although achalasia is an average health condition that can be effectively treated with the help of medical procedures, for conditions that are not treated in a timely manner can trigger several forms of complications as follows.
- Esophageal cancer (doctors will usually recommend endoscopy for patients to detect this cancer early).
- GERD (gastroesophageal reflux disease)
- Esophageal perforation
- The condition of achalasia recurs
- Quite drastic weight loss.
Because achalasia is thought to be related to immune system disorders and genetic factors, the possibility of preventing it is very small.
But to prevent the patient from experiencing complications, several steps such as the following can be attempted:
- Take nutritional supplements to avoid more serious malnutrition.
- Eat small portions, but increased meal times become more frequent.
- Chewing food many times well to make it easier when swallowing it.
- Consume more water, especially when eating.
Preventive steps can be taken just to not exacerbate the condition of achalasia that has already occurred, namely by taking nutritional supplements, chewing food longer, drinking lots of water with meals, and eating small portions of food but more often.