Achalasia, Esophageal Spasm and EoE oh my!

Today in VA morning report we had a lively discussion about esophageal problems with the lead discussant being our local esophagus expert Dr. Dunbar! Some quick PEARLS below!

Achalasia –

  • Typically presents with dysphagia to both solids and liquids
  • Represents failure of relaxation of the LES (in most cases)
  • Remember to perform an EGD on anyone with suspected achalasia in order to rule our “pseudoachalasia” which may be secondary to malignancy.
  • Once EGD is performed, you can confirm achalasia with esophageal manometry.
  • Treatment typically depends on whether the patient is low or high risk for surgery
    • For low risk – Heller myotomy and pneumatic dilatation are the treatments of choice.  Some studies show they are eually as effective
    • For high risk – medical management with botulism injection into the LES can be very helpful

Diffuse Esophageal Spasm –

  • Usually presents with chest pain
  • Has a Corkscrew appearance on barium swallow caused by abnormal muscle contractions
  • Treatment is medical and the drug of choice is a calcium channel blocker like diltiazem.
  • Less effective treatments include nitrates and botulinum toxin

Eosinophilic Esophagitis – EoE

  • Typically presents with dysphagia, food impaction, chest pain, and GERD
  • EGD shows concentric rings and trachealization of the esophagus
  • Biopsy will show many eosinophils (but this can also occur in GERD)
  • Always treat with omeprazole first, because 30-40% of cases will respond to this!
  • If not steroid responsive, fluticasone or budesonide inhalers can be used. These are sprayed into the mouth without inhalation, and then swallowed
  • Pneumatic dilatation can be used for strictures as last resort, but there is increased risk of perforation!!

Thank you Dr. Dunbar for your excellent input on the disorders!

 

Citations:

Imm, Nick. Achalasia. Digital image. N.p., 11 Aug. 2011. Web. 24 July 2017. <patient.info/doctor/achalasia-pro>.

Nevit, Dilman. Corkscrew Esophagus. Digital image. Wikipedia. N.p., 13 Dec. 1993. Web. 24 July 2017. <en.wikipedia.org/wiki/Diffuse_esophageal_spasm>.