Achalasia is an uncommon swallowing disorder that affects about 1 in every 100,000 people. The major symptom of achalasia is usually difficulty with swallowing. Most people are diagnosed between the ages of 25 and 60 years.In achalasia, nerve cells in the esophagus (the tube that carries food from the mouth to the stomach) degenerate for reasons that are not known.
The loss of nerve cells in the esophagus causes two major problems that interfere with swallowing:
- The muscles that line the esophagus do not contract normally, so that swallowed food is not propelled through the esophagus and into the stomach properly.
- The lower esophageal sphincter (LES), a band of muscle that encircles the lower portion of the esophagus, does not function correctly. Normally, the LES relaxes when we swallow to allow swallowed food to enter the stomach.In people with achalasia, the LES fails to relax normally with swallowing. Instead, the LES muscle continues to squeeze the end of the esophagus, creating a barrier that prevents food and liquids from passing into the stomach.
Image 1. Achalasia Cardia presents as difficulty swallowing. The inability to progress the food form the esophagus to the stomach results in significant esophageal dilatation.
The most common symptom of achalasia is difficulty swallowing. Patients often experience the sensation that swallowed material, both solids and liquids, gets stuck in the chest. Some people mistake this for gastroesophageal reflux disease (GERD). However, in achalasia the food is coming from the esophagus, whereas in GERD the material comes from the stomach. Other symptoms include heartburn, chest pain, coughing, pneumonia, weight loss and vomiting.
Achalasia may be suspected based upon symptoms, but tests are needed to confirm the diagnosis including chest x-ray, barium swallow test, esophageal manometry and endoscopy.
Image 2. Achalasia Cardia: Barium swallow test showing the bird’s beak sign secondary to insufficient relaxation of the lower oesophageal sphincter (LOS) and reduction in or absence of oesophageal peristalsis. In the x-ray there is evidence of poor emptying of the barium and dilatation of the esophagus.
Once the esophagus is paralyzed, the muscle cannot work properly again. Specific treatment depends on your age, health condition and the severity of the achalasia. Non surgical options include pneumatic dilatation, botulinum toxin injection (botox), offering temporal control of symptoms, end peroral endoscopic myotomy (POEM) which is an endoscopic technique for performing myotomy of the LES. Surgical treatment of achalasia includes Heller Myotomy with Nissen Fundoplication which remains the standard of practice for all patients who are fit for surgery.
Zenker’s diverticulum is a pouch at the back of the throat at a weak spot where the throat and esophagus join. These diverticula are uncommon and tend to occur in elderly people.Patients with this condition often exhibit no symptoms. When food and saliva fill up the pouch, however, symptoms can occur and may include difficulty swallowing (dysphagia), food regurgitation, cough, hoarseness, pneumonia, bronchitis or episodes of aspirations.
A barium swallow is the most effective way to diagnose a Zenker’s diverticulum. The barium solution fills the pouch in the esophageal wall so that it can be seen on an X-ray.
Surgery is the most common way to treat a symptomatic Zenker’s diverticulum. There are different types of surgery (endoscopic or neck surgery) that may be used to treat this condition. The type of surgery depends on the size and location of the diverticulum.
Image 3. Zenker’s Diverticulum (sagittal view) is an outpouching that occurs at the junction of the lower part of the throat and the upper portion of the esophagus. The pouch forms because the muscle that divides the throat from the esophagus, the cricopharyngeal muscle, fails to relax during swallowing.
Esophageal cancer is cancer that occurs in the esophagus — a long, hollow tube that runs from your throat to your stomach. Your esophagus helps move the food you swallow from the back of your throat to your stomach to be digested.
Esophageal cancer is the sixth most common cause of cancer deaths worldwide. Risk factors for esophageal cancer include, gastroesophageal reflux disease, Barrett’s esophagus, tobacco and alcohol use or particular nutritional habits and obesity.
Signs and symptoms of esophageal cancer include difficulty swallowing (dysphagia), unintentional weight loss, chest pain, pressure or burning, heartburn, coughing or hoarseness. Early esophageal cancer typically causes no signs or symptoms.
Image 4. Esophageal Cancer in the lower third of the esophagus causing stricture and stenosis of the lumen of the esophagus.
Esophageal cancer is classified according to the type of cells that are involved. The type of esophageal cancer you have helps determine your treatment options. Types of esophageal cancer include:
- Adenocarcinoma. It arises from the cells of mucus-secreting glands in the esophagus. Adenocarcinoma occurs most often in the lower portion of the esophagus. Adenocarcinoma is the most common form of esophageal cancer in the United States and Europe, and it affects primarily men.
- Squamous cell carcinoma. The squamous cells are flat, thin cells that line the surface of the esophagus. Squamous cell carcinoma occurs most often in the upper and middle portions of the esophagus. Squamous cell carcinoma is the most prevalent esophageal cancer worldwide.
- Other rare types. Some rare forms of esophageal cancer include small cell carcinoma, sarcoma, lymphoma, melanoma and choriocarcinoma.
Diagnosis of esophageal cancer is done with upper endoscopy and biopsy. Further examinations to determine whether the disease has spread to the lymph nodes or to other areas of the body include a CT chest, abdomen and pelvis, endoscopic ultrasound, bronchoscopy and positron emission tomography (PET).Your doctor uses your cancer stage to select the treatments that are most appropriate for you.
Treatment of esophageal cancer is based on the type of cells involved in your cancer, the staging, your overall health and your preferences for treatment. In general, available treatments include surgery, chemotherapy, combination of chemotherapy and radiotherapy, targeted drug therapy and immunotherapy. The management of patients with esophageal cancer is done through multidisciplinary team meetings (MDT).