Oesophagus and its Disorders Pt. 2

•  What is achalasia?

  Achalasia is a motility disorder of the oesophagus characterised by failure of the lower oesophageal sphincter (LES) to relax and absent peristalsis in the distal oesophagus.
• What is the pathophysiology of achalasia?

  Achalasia results from degeneration of inhibitory myenteric (Auerbach’s) plexus neurons, leading to:

  • Hypertonic LES (failure to relax due to impaired nitric oxide release)
  • Aperistalsis (loss of coordinated oesophageal contractions)
  • Functional obstruction, leading to progressive dysphagia
• What are the key symptoms of achalasia?

  • Progressive dysphagia (solids → liquids)
  • Regurgitation of undigested food
  • Chest pain
  • Weight loss
  • Nocturnal coughing and aspiration
• How is achalasia diagnosed?

  1. Oesophageal manometry (gold standard) – Increased LES pressure, lack of peristalsis
  2. Barium swallow – ‘Bird’s beak’ narrowing at LES
  3. Endoscopy – Rule out malignancy
• What are the treatment options for achalasia?

  • Botulinum toxin injections (temporary relief)
  • Pneumatic dilation (stretching of LES)
  • Heller myotomy (surgical cutting of LES)
  • Peroral Endoscopic Myotomy (POEM)
• What is GORD?

  GORD is a chronic condition where gastric acid refluxes into the oesophagus due to LES dysfunction, causing mucosal damage and symptoms.
• What is the pathophysiology of GORD?

  1. Transient LES relaxation → Acidic gastric contents reflux into oesophagus
  2. Reduced oesophageal clearance → Prolonged acid exposure
  3. Delayed gastric emptying (e.g., due to obesity, hiatal hernia)
  4. Mucosal damage → Inflammation and potential Barrett’s oesophagus
• What are the main risk factors for GORD?

  • Obesity (↑ intra-abdominal pressure)
  • Hiatal hernia (stomach herniates through diaphragm)
  • Smoking, alcohol, caffeine (LES relaxation)
  • Pregnancy (hormonal and pressure effects)
  • Certain medications (e.g., calcium channel blockers, anticholinergics)
• What are the symptoms of GORD?

  • Heartburn (burning chest pain, worse when lying down)
  • Regurgitation of acidic contents
  • Dysphagia (if oesophageal stricture develops)
  • Chronic cough, hoarseness (due to laryngopharyngeal reflux)
  • Dental erosion (acid damage to teeth)
• How is GORD diagnosed?

  1. Clinical symptoms & response to PPIs
  2. 24-hour pH monitoring (gold standard)
  3. Oesophageal manometry (assesses LES function)
  4. Endoscopy (if alarm symptoms: dysphagia, weight loss, bleeding)
• What are the complications of untreated GORD?

  • Oesophagitis – Inflammation of the oesophageal mucosa.
  • Barrett’s oesophagus – Metaplasia of squamous epithelium to columnar epithelium, increasing cancer risk.
  • Oesophageal stricture – Narrowing due to fibrosis from chronic inflammation.
  • Oesophageal adenocarcinoma – A long-term complication of Barrett’s oesophagus.
•  What are the treatment options for GORD?

  • Lifestyle modifications (weight loss, avoid triggers, elevate head of bed)
  • Medications
  • Proton pump inhibitors (PPIs) (e.g., omeprazole)
  • H2 receptor antagonists (e.g., ranitidine)
  • Antacids (short-term relief)
  • Surgical: Nissen fundoplication (tightening of LES)
• What is a hiatal hernia, and how does it affect reflux?

  A hiatal hernia occurs when part of the stomach protrudes through the diaphragm into the thoracic cavity. This weakens the crural diaphragm’s support, reducing the effectiveness of the anti-reflux barrier and increasing the risk of GORD.