The Oesophagus and its Disorders II
• A description of aspects of the pathophysiology of 'achalasia' and
gastroesophageal reflux disease (GORD)
• What is meant by oesophageal manometry (measurement of
pressure)
• The physiological rationale and pharmacological basis for the
various treatment strategies (e.g. lifestyle modification anti-
secretory agents) used for reflux disease will be dealt with in the
later lectures on treatment but they link with this lecture
• The potential long term effects of untreated GORD
Achalasia: Pathophysiology
Achalisa is characterised by a loss of coordinated peristalsis, spasms of the LOS and a
failure of the LOS to relax.
This causes a hypertensive LOS (high pressure) There is also a failure to develop the
wave of peristaltic contractions at the distal oesophagus
Food and liquids hence tend to get stuck and fail to reach the stomach
As a result of this there ends up being long periods of sporadic dysphagia (difficulty
swallowing), regurgitation of food and spasm disorders (chest pain, but not of cardiac
cause, so could be misdiagnosed as angina).
Another thing associated with achalasia is stacking of food within the oesophagus, this
is a rare incidence but can present at any age.
In terms of the aetiology (causation), we know that there is damage to the innervation
of the oesophagus (means a loss of sensory and motor input, needed to massage food
down oesophagus). There may be degenerative lesions of the vagus nerve and a loss of
ganglionic cells in the oesophagus.
Achalasia: Diagnosis—
1 – We can use radiography, by doing a barium swallow, we would see dilation of the
oesophagus with a “beak” deformity at the lower end
2 – Can use oesophageal manometry (quite popular)
-> Can find disorders of motility or peristalsis of oesophagus (assess the motor
function of the UOS, LOS and oesophageal body)
-> Can assess cause of regurgitation, may be associated with achalasia (e.g. reflux of
stomach acids into oesophagus) and could evaluate if you have weak LOS pressure
(this is typically associated with GORD, as allows acidic chyme to go up) -> Having
weak LOS pressure could cause this)
-> Aphagia (can determine the cause of swallowing difficulty)
-> Abnormal oesophageal contractions and food is not effectively reaching the
stomach (oesophageal spasms)
-> Diffuse oesophageal spasm, chest pain coming from oesophagus (angina)
In summary achalasia is associated with
-> Oesophageal motor disorder
, -> Increase in LOS pressure
-> Discoordination of LOS relaxation
-> Absence/failure of peristalsis
Oesophageal Manometry
Oesophageal manometry tests if the oesophagus is contracting and relaxing properly,
it can be used to diagnose swallowing problems (does LOS contract and relax
properly?)
Also allows evaluation of strength of coordination of muscle contractions and also the
relaxation functions of LOS.
This is important as assessing these can tell us if there is achalasia or GORD.
In a normal person we would find there to be a normal LOS pressure and normal
muscle contractions upon swallowing.
Low LOS pressure suggests GORD, but GORD can also occur in individuals with normal
LOS pressure (because it is natural that LOS will open frequently when food goes
through, so gastric chyme may flux up into oesophagus. The saliva we secrete should
be able to clear this acidic material to be pushed into the gut)
A high LOS pressure suggests there is achalasia (greater than 100mmHg), if it is
greater than 200mmHg called nutcracker achalasia.
Oesophageal Manometry: Procedure
-> Anaesthatise, measure strength of muscle contractions and coordinations,
Treatment of Achalasia
Achalasia is a risk factor for squamous carcinoma of the oesophagus, so it is important
we treat it!
We can do an endoscopic balloon dilation of the LOS or perform surgery to weaken the
sphincter. Subsequently if reflux occurs, we may want to perform a fundoplication, this
is where we get some fundal tissue and wrap it around the oesophagus.
We may wish to inhibit the release of acetylcholine, because the contractile effects of
the LOS are mediated by Ach, this can be done by injecting botulinum toxin into the
LOS.
Botulinum toxin injections are well tolerated, safe and efficacious (successful in
producing the desired consequences). It blocks cholinergic nerve endings in the ANS.
Gastro-oesophageal Reflux Disease (GORD)
The gastric contents are irritating and if they flux up into the oesophagus, this will
cause the symptoms of GORD.
Usually reflux (which happens in all of us) stimulates salivation, saliva is an effective
natural antacid. This dilutes and neutralises any refluxed gastric contents.
• A description of aspects of the pathophysiology of 'achalasia' and
gastroesophageal reflux disease (GORD)
• What is meant by oesophageal manometry (measurement of
pressure)
• The physiological rationale and pharmacological basis for the
various treatment strategies (e.g. lifestyle modification anti-
secretory agents) used for reflux disease will be dealt with in the
later lectures on treatment but they link with this lecture
• The potential long term effects of untreated GORD
Achalasia: Pathophysiology
Achalisa is characterised by a loss of coordinated peristalsis, spasms of the LOS and a
failure of the LOS to relax.
This causes a hypertensive LOS (high pressure) There is also a failure to develop the
wave of peristaltic contractions at the distal oesophagus
Food and liquids hence tend to get stuck and fail to reach the stomach
As a result of this there ends up being long periods of sporadic dysphagia (difficulty
swallowing), regurgitation of food and spasm disorders (chest pain, but not of cardiac
cause, so could be misdiagnosed as angina).
Another thing associated with achalasia is stacking of food within the oesophagus, this
is a rare incidence but can present at any age.
In terms of the aetiology (causation), we know that there is damage to the innervation
of the oesophagus (means a loss of sensory and motor input, needed to massage food
down oesophagus). There may be degenerative lesions of the vagus nerve and a loss of
ganglionic cells in the oesophagus.
Achalasia: Diagnosis—
1 – We can use radiography, by doing a barium swallow, we would see dilation of the
oesophagus with a “beak” deformity at the lower end
2 – Can use oesophageal manometry (quite popular)
-> Can find disorders of motility or peristalsis of oesophagus (assess the motor
function of the UOS, LOS and oesophageal body)
-> Can assess cause of regurgitation, may be associated with achalasia (e.g. reflux of
stomach acids into oesophagus) and could evaluate if you have weak LOS pressure
(this is typically associated with GORD, as allows acidic chyme to go up) -> Having
weak LOS pressure could cause this)
-> Aphagia (can determine the cause of swallowing difficulty)
-> Abnormal oesophageal contractions and food is not effectively reaching the
stomach (oesophageal spasms)
-> Diffuse oesophageal spasm, chest pain coming from oesophagus (angina)
In summary achalasia is associated with
-> Oesophageal motor disorder
, -> Increase in LOS pressure
-> Discoordination of LOS relaxation
-> Absence/failure of peristalsis
Oesophageal Manometry
Oesophageal manometry tests if the oesophagus is contracting and relaxing properly,
it can be used to diagnose swallowing problems (does LOS contract and relax
properly?)
Also allows evaluation of strength of coordination of muscle contractions and also the
relaxation functions of LOS.
This is important as assessing these can tell us if there is achalasia or GORD.
In a normal person we would find there to be a normal LOS pressure and normal
muscle contractions upon swallowing.
Low LOS pressure suggests GORD, but GORD can also occur in individuals with normal
LOS pressure (because it is natural that LOS will open frequently when food goes
through, so gastric chyme may flux up into oesophagus. The saliva we secrete should
be able to clear this acidic material to be pushed into the gut)
A high LOS pressure suggests there is achalasia (greater than 100mmHg), if it is
greater than 200mmHg called nutcracker achalasia.
Oesophageal Manometry: Procedure
-> Anaesthatise, measure strength of muscle contractions and coordinations,
Treatment of Achalasia
Achalasia is a risk factor for squamous carcinoma of the oesophagus, so it is important
we treat it!
We can do an endoscopic balloon dilation of the LOS or perform surgery to weaken the
sphincter. Subsequently if reflux occurs, we may want to perform a fundoplication, this
is where we get some fundal tissue and wrap it around the oesophagus.
We may wish to inhibit the release of acetylcholine, because the contractile effects of
the LOS are mediated by Ach, this can be done by injecting botulinum toxin into the
LOS.
Botulinum toxin injections are well tolerated, safe and efficacious (successful in
producing the desired consequences). It blocks cholinergic nerve endings in the ANS.
Gastro-oesophageal Reflux Disease (GORD)
The gastric contents are irritating and if they flux up into the oesophagus, this will
cause the symptoms of GORD.
Usually reflux (which happens in all of us) stimulates salivation, saliva is an effective
natural antacid. This dilutes and neutralises any refluxed gastric contents.
