Achalasia

ACHALASIA

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lack of relaxation of the LES with swallowing a

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A relative obstruction at the level of the sphincter is made worse by a lack of peristaltic waves in the esophagus

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the condition affects primarily adolescents and adults children under the age 4 yr comprise fewer than 5% patients

Clinical M an ifestat ions

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difficulty in swallowing regurgitation of food

cough from overflow of fluids into the trachea failure to gain weight

Diagnosis  roentgenogram and is

confirmed with manometry

Treatm ent Dilating the cardio esophageal junction with a mercury bougie Transient relief of symptoms

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Treatm ent Heller procedure

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surgical division of muscles at the cardioesophageal junction permanent relief of symptoms

GAS TR OES OPHAG EAL RE FLUX ( CH AL AS IA )

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The term chalasia describes the free reflux across a dilated sphincter When the LES is not competent, excessive and passive reflux of gastric contents may cause significant symptoms

Etiology

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reflux may occur with increased intra abdominal pressure The small reservoir capacity of the infant’s esophagus predisposes to vomiting Placement of the gastrostomy tube encourages reflux Mehtylxantines may exacerbate reflux by lowering sphincter tone

Clinical M an ifestat ions signs and symptoms relate directly to the exposure of the esophageal epithelium to refluxed gastric contents In 85% of affected infants excessive vomiting occurs during the 1st week of life an additional 10% have symptoms by 6wk Patients with cerebral palsy, Down syndrome and other causes of developmental delay have an increase incidence of reflux

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Clinical M an ifestat ions

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delayed gastric emptying forceful vomiting aspiration pneumonia

chronic cough wheezing, clubbing and recurrent pneumonia failure to grow and gain weight hemorrhage and/or hematemesis

anorexia

Diag nosis

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In mild cases, a careful clinical assessment may be sufficient for diagnosis barium esophagography under fluoroscopic control

Diag nosis

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esophagoscopy with biopsy

Treatm ent In mil d un compli cated cas es

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keeping the child prone with head elevated at 20-30 degrees thickening the feeding with cereal careful attention to burping

Treatm ent In sev er e cas es

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antacids or cimetidine given four times a day (20-40 mg/kg/24 hr ) metoclopramide (0.5 mg/kg/dose) 4 times a day cisapride, 0.2mg/kg qid

If symptoms do not respond to a 6wk trial of intensive medical therapy, operative treatment may be indicated

Treatm ent

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Bougienage of strictures can provide temporary relief of dysphagia Nissen fundoplication

Tre at ment

Tre at ment

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occasionally, stricture formation is so extensive that colonic interposition is required to replace a portion of the esophagus

Thank You!

jgyif

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