Esophageal Achalasia., El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy

 
This 32 year old man has been suffering from esophageal achalasia for about 10 years, which he has managed by meticulously cutting and chewing all his food. At that time they offered him a surgery, in a public hospital, but he declined it. The incidence of achalasia is approximately 1 per 100,000 people per year. Chagas disease may cause a similar disorder due to Trypanosoma Cruzi.

Video Endoscopic Sequence 1 of 10.

Esophageal Achalasia.

 This 32 year old man has been suffering from esophageal
 achalasia  for about 10 years, which he has managed
 by meticulously cutting and chewing all his food. At that
 time they offered him a surgery, in a public hospital, but he
 declined it.

 At endoscopy, copious amounts of food and liquid were
 seen in the obviously dilated esophagus.

 The incidence of achalasia is approximately 1 per 100,000
 people per year. Chagas disease may cause a similar
 disorder due to Trypanosoma Cruzi.            Medline.   

The exact cause of achalasia is unknown.

                                                     Medline.

 The diagnosis of achalasia should be suspected in anyone
 complaining of dysphagia for solids and liquids with
 regurgitation of food and saliva. The clinical suspicion
 should be confirmed by a barium esophagram showing
 smooth tapering of the lower esophagus leading to the closed
 lower esophageal sphincter (LES), resembling a "bird's
 beak." Esophageal manometry establishes the diagnosis
 showing esophageal aperistalsis and insufficient LES
 relaxation. All patients should undergo upper endoscopy to
 exclude pseudoachalasia arising from a tumor at the
 gastroesophageal junction.

 For more endoscopic details, download the video clip by
 clicking on the endoscopic image. Wait to be downloaded
 complete then Press Alt and Enter for full screen. All
 endoscopic images shown in this Atlas contain video clips.
 We recommend seeing the video clips in full screen mode.
 
Achalasia. Detail of a barium swallow study demonstrating the classic bird's beak deformity of the distal esophagus showing a dilated esophagus. Achalasia is an esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter and by the absence of esophageal peristalsis. Progressive dysphagia and regurgitation can compromise oral intake and lead to malnutrition and weight loss. Treatment of moderate to severe cases of achalasia involves either balloon dilation or myotomy.

Video Endoscopic Sequence 2 of 10.

 Achalasia. Detail of a barium swallow study demonstrating
 the classic bird's beak deformity of the distal esophagus
 showing a dilated esophagus.

 Achalasia is an esophageal motor disorder characterized by
 incomplete relaxation of the lower esophageal sphincter and
 by the absence of esophageal peristalsis. Progressive
 dysphagia and regurgitation can compromise oral intake and
 lead to malnutrition and weight loss. Treatment of moderate
 to severe cases of achalasia involves either balloon dilation
 or myotomy.              
                                          Medline.
Barium Swallow. Barium sulfate is a metallic compound that shows up on x-ray and is used to help see abnormalities in the esophagus and stomach When taking the test, you drink a preparation containing this solution. The x-rays track its path through your digestive system.

Video Endoscopic Sequence 3 of 10.

 Barium Swallow.

 Barium sulfate is a metallic compound that shows up on x-ray
 and is used to help see abnormalities in the esophagus and
 stomach.
 When taking the test, you drink a preparation containing this
 solution. The x-rays track its path through your digestive
 system.

 A simple chest x-ray may reveal distortion of the
 esophagus and absence of air in the stomach, two
 abnormalities that suggest achalasia.

 

 Download the video clip by clicking on the Rx image.
Upper GI series. These problems can be detected with a barium swallow: 1.Narrowing or irritation of the esophagus (the muscular tube between the back of the throat and the stomach) 2. Disorders of swallowing 3. Hiatal hernia (an internal defect that causes the stomach to slide partially into the chest) 4. Abnormally enlarged veins in the esophagus that cause bleeding 5. Ulcers 6. Tumors 7. Polyps (growths that are usually not cancerous, but could be precancerous).

Video Endoscopic Sequence 4 of 10.

Upper GI series.

These problems can be detected with a barium swallow:

1.Narrowing or irritation of the esophagus (the muscular tube between the back of the throat and the stomach)
2. Disorders of swallowing
3. Hiatal hernia (an internal defect that causes the stomach to slide partially into the chest)
4. Abnormally enlarged veins in the esophagus that cause bleeding
5. Ulcers
6. Tumors
7. Polyps (growths that are usually not cancerous, but could be precancerous).

 Download the video clip by clicking on the Rx image.
 
 
Barium swallow showing the entire length of the esophagus with extreme narrowing of the esophago-gastric junction;There is dilatation, tortuosity, S-shaped bend in the lower oesophagus (sigmoid esophagus). There is a smooth narrowing at the lower end of the esophagus referred to as bird-beak appearance. The above appearance is very typical of achalasia of the cardia or cardiospasm.

Video Endoscopic Sequence 5 of 10.

 Barium swallow showing the entire length of the
 esophagus with extreme narrowing of the
 esophago-gastric junction;There is dilatation, tortuosity,
 S-shaped bend in the lower oesophagus (sigmoid
 esophagus). There is a smooth narrowing at the lower end
 of the esophagus referred to as "bird-beak" appearance.
 The above appearance is very typical of achalasia of the
 cardia or cardiospasm.

The bird-beak appearance.

"The bird-beak" appearance.

Barium swallow The esophagus appears dilated, and contrast material passes slowly into the stomach as the LES opens intermittently. The distal esophagus is narrowed and has been described as resembling a bird's beak. The test shows esophageal dilatation.

Video Endoscopic Sequence 6 of 10.

 

 Barium Swallow

    • The esophagus appears dilated, and contrast material passes slowly into the stomach as the LES opens intermittently. The distal esophagus is narrowed and has been described as resembling a bird's beak.
    • The test shows esophageal dilatation.

       Download the video clip by clicking on the Rx
       image.
       

Pneumatic balloon dilation in achalasia. Our patient underwent a dilatation with special ballon used for achalasia. Mechanical therapy for achalasia consists of esophageal dilation, the object of which is to disrupt muscle fibers of the LES, effecting a decrease in LES pressure. Dilation is most commonly performed by using pneumatic balloons. The therapy is successful in decreasing LES pressure in 60-80% of patients; however, this change does not always translate into the relief or improvement of symptoms. Approximately one half of patients experience recurrent symptoms within 5 years. In most of these patients, the disease responds well to repeated dilation therapy.

Video Endoscopic Sequence 7 of 10.

Pneumatic balloon dilation in achalasia.

 Our patient underwent a dilatation with special ballon used
 for achalasia. We do not used fluoroscopic control

                                          Medline.

 Mechanical therapy for achalasia consists of esophageal
 dilation, the object of which is to disrupt muscle fibers of the
 LES, effecting a decrease in LES pressure. Dilation is most
 commonly performed by using pneumatic balloons. The
 therapy is successful in decreasing LES pressure in 60-80% of
 patients; however, this change does not always translate into
 the relief or improvement of symptoms. Approximately one
 half of patients experience recurrent symptoms within 5
 years. In most of these patients, the disease responds well to
 repeated dilation therapy.

Pneumatic dilatation under endoscopic guidance. Pneumatic balloon dilation is considered by many to be the treatment of choice for achalasia of the esophagus. Dilation procedures are done as an outpatient procedure using only mild sedation with fentanyl and midazolam. Sedation is kept to true conscious sedation to assist the operator in evaluating severity of dilation induced chest pain.

Video Endoscopic Sequence 8 of 10.

Pneumatic dilatation under endoscopic guidance.

Pneumatic balloon dilation is considered by many to be the treatment of choice for achalasia of the esophagus. Dilation procedures are done as an outpatient procedure using only mild sedation with fentanyl and midazolam. Sedation is kept to true conscious sedation to assist the operator in evaluating severity of dilation induced chest pain.

 Medline: Long-term follow-up after pneumatic dilation for
 achalasia cardia: factors associated with treatment failure
 and recurrence.
After the esophagus being dilated, we performed a retroflexed maneuver in the esophagus seen the endoscope and the catheter of the balloon. Pneumatic dilatation is considered to be the first line therapy for achalasia, but long-term outcome studies are scarce and limited by their retrospective design.

Video Endoscopic Sequence 9 of 10.

 After the esophagus being dilated, we performed a
 retroflexed maneuver in the esophagus seen the endoscope
 and the catheter of the balloon.

 Pneumatic dilatation is considered to be the first line therapy for
 achalasia, but long-term outcome studies are scarce and limited
 by their retrospective design.

 Medline: Pneumatic balloon dilatation in achalasia: a
 prospective comparison of safety and efficacy with different
 balloon diameters.
The final status of the dilatation. We have performed 24 pneumatic dilations for achalasia in the past 3 years and have had no complication using this protocol. One of the patient of 21 year-old female has Down Syndrome Most prospective studies have shown the effectiveness of pneumatic dilation to be between 60% and 80% and comparable to myotomy.

Video Endoscopic Sequence 10 of 10.

Final status of the dilatation.

 We have performed 24 pneumatic dilations for achalasia in
 the past 3 years and have had no complication using this
 protocol.
 One of the patient of 21 year-old female has Down
 Syndrome Most prospective studies have shown the
 effectiveness of pneumatic dilation to be between 60% and
 80% and comparable to myotomy.

 
Esophageal Achalasia and Bronchoaspiration In this image and the video clip show a bronchoscopy, performed with a regular GI video endoscope in which is observed, material that came from the esophagus that has a achalasia. This 78 year-old female 20 years previously underwent a surgery due to Esophageal Achalasia, (Esophagomyotomy of the lower esophageal sphincter (LES) ). Heller esophagomyotomy, since one month she has vomiting and weight loss. The upper endoscopy shows a typical picture of esophageal achalasia which was dilated with the same balloon that has been showed in this chapter. Esophageal dysfunction progresses through accumulation of ingested material in the superior portion of the esophagus, facilitating the aspiration of this material. This condition is more common in individuals in whom the cough reflex has been lost or suppressed due to neuromuscular disturbances, or due to the use of sedatives or other drugs. In such cases, aspiration pneumonia becomes established.

 Esophageal Achalasia and Bronchoaspiration

 Tracheobronchitis

 In this image and the video clip show a bronchoscopy,
 performed with a regular GI video endoscope in which is
 observed, material that came from the esophagus that has a
 achalasia.

 This 78 year-old female 20 years previously underwent a
 surgery due to Esophageal Achalasia, (Esophagomyotomy
 of the lower esophageal sphincter (LES) ). Heller
 esophagomyotomy, since one month she has vomiting and
 weight loss.

 The upper endoscopy shows a typical picture of esophageal
 achalasia which was dilated with the same balloon that has
 been showed in this chapter. 

 Esophageal dysfunction progresses through accumulation of
 ingested material in the superior portion of the esophagus,
 facilitating the aspiration of this material. This condition is
 more common in individuals in whom the cough reflex has
 been lost or suppressed due to neuromuscular disturbances,
 or due to the use of sedatives or other drugs. In such cases,
 aspiration pneumonia becomes established.

 Pub Med: Surgery for achalasia: long-term results in
 operated achalasic patients.

A 75 year-old female, who 3 months having had weight loss and persiting vomiting. A forceful maneuvering of the endoscope had to be done, in order to overcome the sphincter. The incidence of achalasia is approximately 1 per 100,000 people per year. Chagas disease may cause a similar disorder due to Trypanosoma Cruzi. The exact cause of achalasia is unknown.

Video Endoscopic Sequence 1 of 16.

Esophageal Achalasia,

 A 75 year-old female, who 3 months ago had started with
 weight loss and persiting vomiting.
 A forceful maneuvering of the endoscope had to be done, in
 order to overcome the sphincter.
 The incidence of achalasia is approximately 1 per 100,000
 people per year. Chagas disease may cause a similar
 disorder due to Trypanosoma Cruzi.
 The exact cause of achalasia is unknown.
The esophagus is found to be dilated with rest of food. Achalasia is a rare disease of the muscle of the esophagus which is usually diagnosed in young adults. The term achalasia means "failure to relax" and refers to one of the abnormalities of the esophagus seen in the disease, specifically. The inability of the muscle at the lower end of the esophagus (the lower esophageal sphincter) to open and let food pass into the stomach. In addition, the muscle of the lower half of the esophagus does not contract normally to propel food down the esophagus and into the stomach. Both of these abnormalities result in food sticking in the esophagus after it is swallowed.

Video Endoscopic Sequence 2 of 16.

 The esophagus is found to be dilated with rest of food.
 Achalasia is a rare disease of the muscle of the esophagus
 which is usually diagnosed in young adults.
 The term achalasia means "failure to relax" and refers to
 one of the abnormalities of the esophagus seen in the
 disease, specifically. the inability of the muscle at the
 lower end of the esophagus (the lower esophageal
 sphincter) to open and let food pass into the stomach. In
 addition, the muscle of the lower half of the esophagus
 does not contract normally to propel food down the
 esophagus and into the stomach. Both of these
 abnormalities result in food sticking in the esophagus after
 it is swallowed.
Retroflexed view of the fundus shows a cardias so tight, the retroflex maneuver can not be performed into the esophagus.

Video Endoscopic Sequence 3 of 16.

 Retroflexed view of the fundus shows a cardias so
 tight, the retroflex maneuver can not be performed
 into the esophagus.
 
 

 
Esofagogram. X-ray finding in a patient with achalasia.

Video Endoscopic Sequence 4 of 16.

Esofagogram.

        X-ray finding in a patient with achalasia.
                
Pneumatic dilation in achalasia under direct visualization. The image and the video display a guide wire placed first To introduce the balloon. A nonsurgical treatment of esophageal achalasia, where the lower esophageal and cardial sphincter is disrupted by overdistension of the circular muscular fibres. The balloon is positioned over a guide wire and positioned through an endoscope under direct vision.

Video Endoscopic Sequence 5 of 16.

 Pneumatic dilation in achalasia under direct visualization.
 
 The image and the video display a guide wire placed first
 To introduce the balloon.

 A nonsurgical treatment of esophageal achalasia, where
 the lower esophageal and cardial sphincter is disrupted by
 overdistension of the circular muscular fibres. The balloon
 is positioned over a guide wire and positioned through an
 endoscope under direct vision.
The image and the video display the cardias with the guide wire and the distal tip of the balloon catether.

Video Endoscopic Sequence 6 of 16.

 The image and the video display the cardias with the guide
 wire and the distal tip of the balloon catether.

Starting the maneuvers to perform dilatation the cardias. Achalasia Dilator. Starting the maneuvers to perform dilatation the cardias. Pneumatic dilation is the most common first-line therapy for the treatment of achalasia. The aim of dilation is a controlled disruption of circular muscle fibres of the lower esophageal sphincter to reduce the functional obstruction.

Video Endoscopic Sequence 7 of 16.

Achalasia Dilator.

 Starting the maneuvers to perform dilatation the cardias.

 Pneumatic dilation is the most common first-line therapy for
 the treatment of achalasia.
 The aim of dilation is a controlled disruption of circular
 muscle fibres of the lower esophageal sphincter to reduce
 the functional obstruction.
Balloon Dilatation. Balloon Dilatation. The image and the video display the balloon with water insuflation. Considering the pros and cons of other effective forms of treatment of achalasia (esophagomyotomy and intrasphincteric injection of botulinum toxin), pneumatic dilation is still the treatment of choice in the majority of patients with achalasia.

Video Endoscopic Sequence 8 of 16.

Balloon Dilatation.

 The image and the video display the balloon with water
 insuflation.

 Considering the pros and cons of other effective forms of
 treatment of achalasia (esophagomyotomy and
 intrasphincteric injection of botulinum toxin), pneumatic
 dilation is still the treatment of choice in the majority of
 patients with achalasia.
The image and the video clip display the balloon in retroflexed image.

Video Endoscopic Sequence 9 of 16.

 The image and the video clip display the balloon in
 retroflexed image.

 Medline: Short-term and long-term results of endoscopic
 balloon dilation for achalasia: 12 years' experience.
 

 
The expansion causes certain perístalsis.

Video Endoscopic Sequence 10 of 16.

 The expansion causes certain perístalsis.
The video clip exhibit more maneuvers. Achalasia is an esophageal motor disorder characterized by increased lower esophageal sphincter (LES) pressure, diminished-to-absent peristalsis in the distal portion of the esophagus composed of smooth muscle, and lack of a coordinated LES relaxation in response to swallowing. Primary achalasia is the most common subtype and is associated with loss of ganglion cells in the esophageal myenteric plexus These important inhibitory neurons induce LES relaxation and coordinate proximal-to-distal peristaltic contraction of the esophagus. Secondary achalasia is relatively uncommon. This condition exists when a process other than intrinsic disease of the esophageal myenteric plexus is the etiology. Examples of maladies causing secondary achalasia include certain malignancies, diabetes mellitus, and Chagas disease.

Video Endoscopic Sequence 11 of 16.

 The video clip exhibit more maneuvers.
 Achalasia is an esophageal motor disorder characterized by
 increased lower esophageal sphincter (LES) pressure,
 diminished-to-absent peristalsis in the distal portion of the
 esophagus composed of smooth muscle, and lack of a
 coordinated LES relaxation in response to swallowing.

 Primary achalasia is the most common subtype and is associated
 with loss of ganglion cells in the esophageal myenteric plexus
 These important inhibitory neurons induce LES relaxation and
 coordinate proximal-to-distal peristaltic contraction of the
 esophagus.

 Secondary achalasia is relatively uncommon. This condition exists
 when a process other than intrinsic disease of the esophageal
 myenteric plexus is the etiology. Examples of maladies causing
 secondary achalasia include certain malignancies, diabetes
 mellitus, and Chagas disease.

Achalasia Dilator. The downside is that this balloon is much larger than the balloon dilators normally used to dilate an esophageal stricture or tight hiatal hernia. It has to be big enough to actually rip the tight LES valve and weaken it.

Video Endoscopic Sequence 12 of 16.

Achalasia Dilator.

 The downside is that this balloon is much larger than the
 balloon dilators normally used to dilate an esophageal
 stricture or tight hiatal hernia. It has to be big enough to
 actually rip the tight LES valve and weaken it.
Neuromuscular disorder of the esophagus characterized by a lack of reflex relaxation of the distal esophageal sphincter, normally induced by swallowing. Achalasia produces a functional obstruction of the esophagus with proximal dilatation. However, the disease involves the entire organ in which the normal neuromuscular disorder peristaltic waves are replaced by simultaneous contractions. Achalasia occurs mainly in adults and rarely in children. Neuromuscular disorder of the oesophagus characterized by a lack of reflex relaxation of the distal oesophageal sphincter, normally induced by swallowing. Achalasia produces a functional obstruction of the oesophagus with proximal dilatation. However, the disease involves the entire organ in which the normal neuromuscular disorder peristaltic waves are replaced by simultaneous contractions. Achalasia occurs mainly in adults and rarely in children.

Video Endoscopic Sequence 13 of 16.

Achalasia

 Neuromuscular disorder of the esophagus characterized
 by a lack of reflex relaxation of the distal esophageal
 sphincter, normally induced by swallowing. Achalasia
 produces a functional obstruction of the esophagus with
 proximal dilatation. However, the disease involves the
 entire organ in which the normal neuromuscular disorder
 peristaltic waves are replaced by simultaneous
 contractions. Achalasia occurs mainly in adults and rarely
 in children.
More forceful maneuver to perform dilation Forceful balloon dilation was the mainstay of treatment for achalasia for many years. In this procedure, a pneumatic balloon is passed down the esophagus, half above and half below the LES. The balloon is then rapidly inflated for about a minute. As the balloon expands, it forcefully stretches and weakens the LES. Forceful pneumatic dilatation can be very successful and may last for a decade or longer.

Video Endoscopic Sequence 14 of 16.

 More forceful maneuver to perform dilation
 Forceful balloon dilation was the mainstay of treatment for
 achalasia for many years. In this procedure, a pneumatic
 balloon is passed down the esophagus, half above and half
 below the LES. The balloon is then rapidly inflated for
 about a minute. As the balloon expands, it forcefully
 stretches and weakens the LES. Forceful pneumatic
 dilatation can be very successful and may last for a decade
 or longer.
Final status of the dilatation of the cardias. Best long term results are obtained if the lower esophageal sphincter pressure can be reduced below 10 mmHg.

Video Endoscopic Sequence 15 of 16.

 Final status of the dilatation of the cardias.

 Best long term results are obtained if the lower esophageal
 sphincter pressure can be reduced below 10 mmHg.

A endoscopic follow up five days after the dilatation. We underline the simplicity, safety and effectiveness of pneumatic dilatation under direct visualization it should be used as first-line treatment of achalasia, surgery being performed only when dilatation fails. In conclusion, pneumatic dilatation performed using a consistent technique is effective long-term therapy for achalasia patients of all ages. Most patients require only one dilatation.

Video Endoscopic Sequence 16 of 16.

A endoscopic follow up five days after the dilatation.

 We underline the simplicity, safety and effectiveness of
 pneumatic dilatation under direct visualization it should be
 used as first-line treatment of achalasia, surgery being
 performed only when dilatation fails.
 In conclusion, pneumatic dilatation performed using a
 consistent technique is effective long-term therapy for
 achalasia patients of all ages. Most patients require only
 one dilatation.
 
Esophageal Achalasia A 49 year-old female who have been complained of solid food dysphagia and liquids intermittently, weight loss, retroesternal fullness. The image and video display liquid and food retained as a consequence of aperistalsis.

Video Endoscopic Sequence 1 of 7.

Esophageal Achalasia

 A 49 year-old female who have been complained of solid
 food dysphagia and liquids intermittently, weight loss,
 retroesternal fullness. The image and video display liquid
 and food retained as a consequence of aperistalsis.
Esophageal Achalasia Image shows cardias, the cardias proved to be so tight its appears more like a narrows pylorus. The patient with achalasia classically present with progressive dysphagia for both solids and liquids, bland regurgitation of food and saliva with chest pain.

Video Endoscopic Sequence 2 of 7.

Esophageal Achalasia

 Image shows cardias, the cardias proved to be so tight its
 appears more like a narrows pylorus.
 The patient with achalasia classically present with
 progressive dysphagia for both solids and liquids, bland
 regurgitation of food and saliva with chest pain.
 
Achalasia. It took forceful maneuvering of the endoscope to overcome the sphincter. Pathophysiologic studies of achalasia have primarily identified neural lesion involving loss of ganglion cell within the myenteric plexus, degeneration of the vagus nerve, and changes in the dorsal motor nucleus of the vagus. These changes result in aperistalsis in the esophageal body, impairment of lower esophageal sphincter relaxation.

Video Endoscopic Sequence 3 of 7.

                    Achalasia

 It took forceful maneuvering of the endoscope to overcome
 the sphincter.  
 Pathophysiologic studies of achalasia have primarily
 identified neural lesion involving loss of ganglion cell within
 the myenteric plexus, degeneration of the vagus nerve, and
 changes in the dorsal motor nucleus of the vagus.
 These changes result in aperistalsis in the esophageal
 body, impairment of lower esophageal sphincter relaxation.
Achalasia. Monilias are observed. Pathophysiology: The exact etiology of achalasia is not known. The most widely accepted current theories implicate autoimmune disorders, infectious diseases, or both. The last decade has witnessed much progress in the understanding of the cellular and molecular derangements in achalasia. Degeneration of the esophageal myenteric plexus of Auerbach is the primary histologic finding. However, with early achalasia, a mixed inflammatory infiltrate of T cells, mast cells, and eosinophils is found in association with myenteric neural fibrosis and with a selective loss of inhibitory postganglionic neurons from the Auerbach plexus. In these patients with early achalasia, neurons of the myenteric plexus are relatively well preserved.

Video Endoscopic Sequence 4 of 7.

Achalasia.

               Monilias are observed.

 Pathophysiology: The exact etiology of achalasia is not known.
 The most widely accepted current theories implicate autoimmune
 disorders, infectious diseases, or both. The last decade has
 witnessed much progress in the understanding of the cellular and
 molecular derangements in achalasia.

 Degeneration of the esophageal myenteric plexus of Auerbach is
 the primary histologic finding. However, with early achalasia, a
 mixed inflammatory infiltrate of T cells, mast cells, and eosinophils
 is found in association with myenteric neural fibrosis and with a
 selective loss of inhibitory postganglionic neurons from the
 Auerbach plexus. In these patients with early achalasia, neurons of
 the myenteric plexus are relatively well preserved.   

Achalasia. Maneuvering with the biopsy forceps troughs the cardias and taken the biopsy to rule out malignancy.

Video Endoscopic Sequence 5 of 7.

Esophageal Achalasia.

 Maneuvering with the biopsy forceps troughs the cardias
 and taken the biopsy to rule out malignancy.
 
Esophageal Achalasia. Sir Thomas Willis first described achalasia in 1674. Willis successfully treated a patient by dilating the LES with a cork-tipped whalebone. Not until 1929 did Hurt and Rake first realize that the primary pathophysiology resulting in achalasia was a failure in LES relaxation.

Video Endoscopic Sequence 6 of 7.

Esophageal Achalasia.

 Sir Thomas Willis first described achalasia in 1674. Willis
 successfully treated a patient by dilating the LES with a
 cork-tipped whalebone. Not until 1929 did Hurt and Rake first
 realize that the primary pathophysiology resulting in achalasia was
 a failure in LES relaxation.

 
Achalasia. Retroflexed view of the fundus shows a cardias so tight, the retroflex maneuver can not be performed into the esophagus.

Video Endoscopic Sequence 7 of 7.

Achalasia.

 Retroflexed view of the fundus shows a cardias so tight,
 the retroflex maneuver can not be performed into the
 esophagus.

A 42 year-old man, who presented weight loss of more than 30 pounds and vomiting, during the previous 6 months. At that time, the upper endoscopy performed in a public hospital only explored the esophagus, since they could not get into the stomach due to an obstruction. 3 months after that he was refered to our endoscopic unit and a balloon dilation of esophageal stricture, under direct endoscopic visualization, had to be perform. However, the biopsies were negative to carcinoma.

Video Endoscopic Sequence 1 of 4.

 Pseudo Achalasia

 A 42 year-old man, who presented weight
 loss of more than 30 pounds and vomiting, during the
 previous 6 months. At that time, the upper endoscopy
 performed in a public hospital only explored the esophagus,
 since they could not get into the stomach due to an
 obstruction.
 3 months after that he was refered to our endoscopic unit
 and a balloon dilation of esophageal stricture, under direct
 endoscopic visualization, had to be perform.
 However, the biopsies were negative to carcinoma.
The patient did not returned until the date of a new endoscopy; he had gained 30 pounds but the cardias needed a new dilatation.

             Video Endoscopic Sequence 2 of 4.

 The patient did not returned until the date of a new
 endoscopy; he had gained 30 pounds but the cardias
 needed a new dilatation.

 
The image and video display some typical parameters of criteria of a malign ulcer, gastric cardias in retrofled image.

Video Endoscopic Sequence 3 of 4.

 The image and video display some typical parameters of
 criteria of a malign ulcer, gastric cardias in retrofled
 image.

This image, which did not appear during the previous three months months endoscopy. It is a typical neoplastic infiltration. There are, depressed mucosal surface, abrupt termination of folds, fold tapering and ulceration. This image is a continuation of the neoplasia of the gastric cardias which infiltrates into the lesser curvature of the gastric fornix.

Video Endoscopic Sequence 4 of 4.

 This image, which did not appear during the previous three
 months endoscopy.
 It is a typical neoplastic infiltration. There are, depressed
 mucosal surface, abrupt termination of folds, fold tapering
 and ulceration.
 The biopsies were negatives to malignancy.
Impaction of foreign bodies (piece of meat) due to a Esophageal Achalasia. This 65 year-old female presented dysphagia, endoscopy finding: piece of meet impacted in the middle third of the esophagus and spasm of the lower third consistently of esophageal achalasia. this piece of meat was founded 3 days previously and it persisted in such position.

Video Endoscopic Sequence 1 of 5.

Impaction of foreign bodies (piece of meat) due to a Esophageal Achalasia.

 This 65 year-old female presented dysphagia, endoscopy
 finding: piece of meet impacted in the middle third of the
 esophagus and spasm of the lower third consistently of
 esophageal achalasia. this piece of meat was founded 3
 days previously and it persisted in such position.

 
With diathermy loop this piece of meat was extracted

Video Endoscopic Sequence 2 of 5.

Meat Bolus

With diathermy loop this piece of meat was extracted

 
The GE junction was tight suggestive of motor dysphagia.

Video Endoscopic Sequence 3 of 5.

 The GE junction was tight suggestive of motor dysphagia

 
Balloon dilatation (pneumatic dilatation).

Video Endoscopic Sequence 4 of 5.

Balloon dilatation (pneumatic dilatation)

This case the balloon was filled with water instead of air

 Pneumatic dilatation is considered to be the first line
 therapy for achalasia, but long-term outcome studies are
 scarce and limited by their retrospective design. There is
 also no consensus on the optimal method for performing
 pneumatic dilation as regard to balloon diameter, amount
 and the rate inflation pressure.

 Graded pneumatic balloon dilatation with 30 mm diameter
 and slower rate of balloon inflation is an effective and safe
 initial method of therapy for achalasia. The duration of
 remission can be extended by repeated dilatation with
 larger size balloon.
Status after dilatation with balloon

Video Endoscopic Sequence 5 of 5.

Status after dilatation with balloon

 

  • Achalasia is the best understood example of an esophageal motility disorder and characterized by esophageal aperistalsis and impaired relaxation of the lower esophageal sphincter.
  • The histopathology of achalasia involves inflammation of the myenteric plexus of the esophagus with diminution of ganglion cells. Significant reduction in nitric oxide synthase containing neurons has been demonstrated using immunohistochemical staining.
  • Autoimmune, neurodegenerative, and viral etiologies have been implicated in the pathogenesis of achalasia. However, the exact cause has yet to be elucidated.
  • Pharmacologic studies in achalasia patients support the selective loss of inhibitory, nitrergic neurons with preservation of cholinergic innervation.
AchalasiaResidualFood1

Video Endoscopic Sequence 1 of 11.

This 50 year-old lady presented with progressive dysphagia to solids and liquids.
A "tight" gastroesophageal junction retroflexed image Sir Thomas Willis is credited with the first report of a patient with achalasia in 1674. Von Mikulicz in 1882 and Einhorn in 1888 hypothesized that the disease was due to the absence of opening of the cardia or "cardiospasm." Over the past three centuries, achalasia has emerged as an important model by which to understand the pathophysiology and therapy of motility disorders emanating from a defect in the enteric nervous system. It is the most extensively studied and readily treatable gastrointestinal motor disorder. This review discusses current concepts in achalasia with an emphasis on the pathophysiology and etiology of the disease. Specific secondary etiologies of achalasia are discussed that provide insight into mechanisms responsible for the neurodegeneration that characterizes the disorder. Diffuse esophageal spasm is also discussed, although there is a paucity of data regarding this condition.

Video Endoscopic Sequence 2 of 11.

 A "tight" gastroesophageal junction retroflexed image

 Sir Thomas Willis is credited with the first report of a
 patient with achalasia in 1674. Von Mikulicz in 1882 and
 Einhorn in 1888 hypothesized that the disease was due to
 the absence of opening of the cardia or "cardiospasm."
 Over the past three centuries, achalasia has emerged as
 an important model by which to understand the
 pathophysiology and therapy of motility disorders
 emanating from a defect in the enteric nervous system.
 It is the most extensively studied and readily treatable
 gastrointestinal motor disorder. This review discusses
 current concepts in achalasia with an emphasis on the
 pathophysiology and etiology of the disease. Specific
 secondary etiologies of achalasia are discussed that
 provide insight into mechanisms responsible for the
 neurodegeneration that characterizes the disorder. Diffuse
 esophageal spasm is also discussed, although there is a
 paucity of data regarding this condition.

 
Achalasia occurs with an incidence of approximately 1:100,000 with an equal gender distribution. It occurs at all ages with an increase in incidence observed after the seventh decade. Dysphagia is the predominant symptom and it is typically accompanied by regurgitation. Upper endoscopy is often the first test used to evaluate patients with suspected achalasia and may detect esophageal dilatation with retained saliva or food. A barium esophagram can be highly suggestive of the diagnosis of achalasia, particularly when there is the combination of esophageal dilatation with retained food and barium and a smooth, tapered constriction of the gastroesophageal junction. Quantitative assessment of the degree of esophageal emptying of barium over time may increase the diagnostic sensitivity of the esophagram for achalasia and serves as a valuable means by which to follow patients response to therapy.

Video Endoscopic Sequence 3 of 11.

 Achalasia occurs with an incidence of approximately
 1:100,000 with an equal gender distribution. It occurs at all
 ages with an increase in incidence observed after the
 seventh decade. Dysphagia is the predominant symptom
 and it is typically accompanied by regurgitation. Upper
 endoscopy is often the first test used to evaluate patients
 with suspected achalasia and may detect esophageal
 dilatation with retained saliva or food. A barium
 esophagram can be highly suggestive of the diagnosis of
 achalasia, particularly when there is the combination of
 esophageal dilatation with retained food and barium and a
 smooth, tapered constriction of the gastroesophageal
 junction. Quantitative assessment of the degree of
 esophageal emptying of barium over time may increase the
 diagnostic sensitivity of the esophagram for achalasia and
 serves as a valuable means by which to follow patients
 response to therapy.
The symptoms have a slow onset and progress gradually; many people delay seeking medical attention until symptoms are advanced. The major symptom is difficulty swallowing (liquids or solids). Some people compensate by eating more slowly and using specific maneuvers, such as lifting the neck or throwing the shoulders back, to improve emptying of the esophagus Other symptoms can include chest pain, regurgitation of swallowed food and liquid, heartburn, difficulty burping, a sensation of fullness or a lump in the throat, hiccups, and weight loss.

Video Endoscopic Sequence 4 of 11.

 The symptoms have a slow onset and progress gradually;
 many people delay seeking medical attention until
 symptoms are advanced. The major symptom is difficulty
 swallowing (liquids or solids). Some people compensate by
 eating more slowly and using specific maneuvers, such as
 lifting the neck or throwing the shoulders back, to improve
 emptying of the esophagus Other symptoms can include
 chest pain, regurgitation of swallowed food and liquid,
 heartburn, difficulty burping, a sensation of fullness or a
 lump in the throat, hiccups, and weight loss.
Balloon dilatation mechanically stretches the contracted LES. A Rigiflex balloon with a 30 mm diameter was advanced over the guide wire with the middle of the balloon traversing the GE junction,

Video Endoscopic Sequence 5 of 11.

Balloon dilatation mechanically stretches the contracted LES.

 A Rigiflex balloon with a 30 mm diameter was advanced
 over the guide wire with the middle of the balloon
 traversing the GE junction.

 
Performing balloon dilatation under endoscopic observation as an outpatient procedure is simple, safe and efficacious for treating patients with achalasia and referral of surgical myotomy should be considered for patients who do not respond to medical therapy or individuals that do not desire pneumatic dilatations.

Video Endoscopic Sequence 6 of 11.

 Performing balloon dilatation under endoscopic observation
 as an outpatient procedure is simple, safe and efficacious
 for treating patients with achalasia and referral of surgical
 myotomy should be considered for patients who do not
 respond to medical therapy or individuals that do not
 desire pneumatic dilatations.

 The middle of the balloon is generally held about 1 cm
 above the GE junction as traction of the balloon upon
 inflation moves the balloon distally into the stomach. Once
 the balloon is in place, the catheter is held firmly against
 the bite block to prevent migration of the balloon.
 Here, the waist of the balloon is noted, which is at the tight
 lower esophageal sphincter. The balloon is inflated slowly
 until the waist is obliterated, which is usually 7-10 psi.
 There is no consensus on the duration of inflation. Some
 centers repeat the dilation to document that the
 subsequent pressure is lower.

The image and the video clip show the GI junction that has been dilated. Pneumatic dilatation is an effective procedure in the treatment of primary achalasia during the short- and long-term period.

Video Endoscopic Sequence 7 of 11.

The image and the video clip show the GI junction that has been dilated.

Pneumatic dilatation is an effective procedure in the treatment of primary achalasia during the short- and long-term period.

 
The rationale for dilation is to produce a controlled tear of the lower esophageal sphincter, which will result in relief of distal esophageal obstruction. This is the most effective non-surgical treatment of achalasia..

Video Endoscopic Sequence 8 of 11.

 The rationale for dilation is to produce a controlled tear of
 the lower esophageal sphincter, which will result in relief of
 distal esophageal obstruction. This is the most effective
 non-surgical treatment of achalasia.

 
The image and the video clip show in retroflexed the balloon in the gastric fundus.

Video Endoscopic Sequence 9 of 11.

The image and the video clip show in retroflexed the balloon in the gastric fundus.
Balloon dilatation reduces the basal LES pressure by tearing muscle fibers.

Video Endoscopic Sequence 10 of 11.

 

  •  Balloon dilatation reduces the basal LES pressure by tearing muscle fibers
Status after dilatation with balloon .

Video Endoscopic Sequence 11 of 11.

Status after dilatation with balloon