Pseudoachalasia - Causes and Treatment

Introduction

Achalasia is an esophageal disorder characterized by difficulty in swallowing soft and hard foods. Pseudoachalasia mimics the symptoms of achalasia. When the food enters the esophagus, it passes through the passage by a movement of contraction and relaxation called peristalsis. A group of muscles in the lower end of the esophagus, which is called the lower esophageal sphincter, present above the stomach contracts and closes to prevent the food from entering back into the esophagus. The failure of relaxation in the peristaltic movement causes the esophagus to remain contracted, further preventing food from entering the stomach. It is a rare condition accounting for only four percent of patients who present with achalasia.

What Causes Achalasia?

The causes of achalasia includes:

• Loss of inhibitory innervation of the lower esophageal sphincter relaxation for the accommodation of food.

• Nerve cell degeneration signals the brain to relax the esophageal sphincter.

• The exact cause for this remains unknown, though autoimmune disease or some infection may be a factor.

• Chagas disease, where there is an infection of the esophagus caused by a parasite called Trypanosoma cruzi, which causes nerve cell degeneration.

• Other conditions like amyloidosis (the deposition of an abnormal protein that will usually be produced in the bone marrow).

• Sarcoidosis (tiny inflammatory cell growth in parts of the body like lymph nodes, skin, and eyes).

• Juvenile Sjogren syndrome (a disease affecting saliva and tear-producing glands which usually occurs over a long period of time in children) can also cause this condition.

What Causes Pseudoachalasia?

The causes of pseudo achalasia includes:

• Malignancies (cancerous lesions).

• Disturbances in esophageal mobility.

What Are the Clinical Manifestations of Pseudoachalasia?

• Both genders are affected equally.

• It is usually diagnosed in adults between the age of 25 years to 60 years.

• The annual incidence of approximately 1 in 100000.

What Are the Symptoms of Achalasia?

The symptoms of achalasia includes

• Difficulty in swallowing.

• A feeling of food being struck.

• Chest pain which can often be mistaken for cardiac pain.

• Heartburn.

• Cough at night time.

• Weight loss.

• Difficulty in belching (it is the process of bringing up air from the stomach).

• Recurring pneumonia (infection in air sacs of lungs which may be filled with fluid or pus) due to food passing through the lower airways.

How To Diagnose This Condition?

A good medical history is a significant key in diagnosing this condition. Reviewing the history should be made carefully by checking the timings of the symptoms and eliminating other conditions which would present with the same kind of symptoms.

• Endoscopy: In this procedure, a tube containing a small camera with a lens and a light is inserted into the esophagus to visualize the internal structure of the food pipe. This will help in checking whether there is any narrowing of the esophagus. It will also help in viewing the presence of any tumors or any other cancerous lesions.

• X-Ray of the Esophagus: In this procedure, the patient would be given barium, which is a chemical agent, to swallow, which would produce a different contrast color while taking an X-ray. This would be useful in viewing the outline of the esophagus and checking whether there is a constriction or narrowing of the esophageal sphincter.

• Radiographic Studies: This indicates widened mediastinum (space between the lungs in which the esophagus and various other anatomical structures are located) caused by the dilated esophagus.

• Manometry: This procedure helps in checking the pressure exerted by the esophageal sphincter. It is done by passing a thin tube into the esophagus.

• Endoscopic Ultrasonography: An ultrasound device attached to the end of a tube that emits sound waves that will generate pictures of the region where the tube is inserted. It is a reliable means of detecting carcinoma and lymph node enlargement near a tumorous lesion.

• Computed Tomography: It is a procedure where a combination of X-rays taken at different angles is processed in a computer to produce cross-sectional images. This will help in showing cancerous lesions in the esophagus.

What Are the Treatment Options for This Condition?

The first line of treatment for achalasia would be dilation of the esophagus by a balloon. An inflated balloon is passed down inside the esophagus and inflated near the sphincter to make it wide. Esophageal dilation is effective in 70 percent of patients.

• Esophagomyotomy, the procedure in which the sphincter muscle is cut down, which would allow the esophagus to open.

• Drugs like Nifedipine, a calcium channel blocker, help reduce contractions and provide good relief by opening the esophagus.

• Botulinum toxin injection into the esophagus will paralyze the esophageal sphincter muscle, allowing it to relax for a minimum period of two years.

What Is the Difference Between Achalasia and Pseudoachalasia?

Conclusion

Thus, the most challenging part of this condition is differentiating it from primary achalasia. Even though it would be difficult, with the advancement in technology and using the right diagnostic methods, analyzing the medical history would provide a clear picture of this condition. The assessment of clinical features, along with the right interpretation of diagnostic tests, will be essential for differentiating pseudoachalasia from idiopathic achalasia.