Achalasia

　　Etiology: The exact etiology and pathogenesis of achalasia are still unclear. The basic defect is the abnormality of the neuromuscular system. The pathological findings show that there are varying degrees of muscle nerve plexus lesions in the body of the esophagus and the lower esophageal sphincter. Mononuclear cells infiltrate the entire ganglion cells in the Auerbach plexus, replaced by fibrous tissue. The vagus nerve has Wallerian degeneration, and the neurons in the dorsal motor nucleus are lost. The esophageal smooth muscle appears normal under light microscopy but shows surface membrane shedding and cell atrophy under electron microscopy. However, it is not clear whether these changes are primary or secondary. In summary, the results of histological, ultrastructural, and pharmacological studies indicate that the esophagus in achalasia has lost innervation, and the lesions are located in the brainstem, vagus nerve fibers, Auerbach plexus, and intramuscular nerve fibers, but it cannot clarify where the primary lesion is located. It may be a diffuse neurodegenerative change or affected by neurotoxic substances that affect all the nervous system from the brain to the muscle fibers.

　　1. Respiratory complications

　　About 10% of patients may have cancer, which is more common in children. Because of the aspiration pneumonia, bronchial dilation, lung abscess, and pulmonary fibrosis caused by vomiting and regurgitation, the inhalation of atypical mycobacteria and the retention of oil in the esophagus can induce chronic changes in the lungs, similar to clinical and X-ray findings of tuberculosis. The presence of acid-fast bacilli in sputum may be atypical mycobacteria, and should not be mistaken for tuberculosis bacilli.

　　2. Cancer

　　It is reported that 2% to 7% of patients may have esophageal cancer, especially those with a course of disease of more than 10 years and marked esophageal dilation with severe retention. The main cause of esophagitis is the chronic inflammatory stimulus caused by food retention, and the esophageal muscle layer incision or dilation after surgery cannot prevent the occurrence of cancer. There are reports that cancer can occur many years after the surgery is successful. Therefore, it should be carefully observed whether there is concurrent esophageal cancer, and biopsy should be performed if there is any suspicious condition. Huang Guojun and Zhang Wei reported that the incidence of gender in patients with achalasia and esophageal cancer is similar to that of esophageal cancer, with males being the main group, but the onset age of cancer with achalasia is lighter than that of esophageal cancer patients. The average age of patients with achalasia is 48 to 51 years, and the age of patients without achalasia is 62 to 67 years. Tumors are more common in the middle segment of the esophagus, followed by the lower and upper segments. Diagnosis is often delayed because the gastrointestinal symptoms of the patients are often misdiagnosed as achalasia. It is only noticed when the tumor grows to a larger size, causing obstruction and dilatation of the esophagus. Symptoms include weight loss, difficulty in swallowing from intermittent to progressive, and regurgitation and vomiting of blood-stained material or anemia before it is discovered that there may be a case of esophageal cancer. In addition to barium meal X-ray examination, endoscopic biopsy and cytological brush examination should be performed.

　　3. Esophagitis

　　Due to food retention in the esophagus caused by achalasia, endoscopic examination can show esophagitis and mucosal ulcers caused by it, which may cause bleeding. A few cases may develop spontaneous perforation. Esophageal-tracheal fistula, body weakness, or those who have received antibiotic treatment or have granulocytopenia may be complicated with candidal infection, with white spots seen on inflammatory mucosa in endoscopy. Smear and biopsy can be used for diagnosis. Treatment should first perform dilation to relieve esophageal retention. For those who cannot tolerate strong dilation, aspiration and drainage can be used to maintain esophageal emptying, and antibiotics should be used at the same time.

　　4. Other complications

　　Due to the esophageal dilation caused by achalasia, the complications such as the formation of diaphragmatic hernia-type diverticula due to increased intraluminal tension can be treated at the same time as the treatment for achalasia. A few patients may develop joint complications similar to rheumatoid arthritis, and the symptoms can be relieved after the treatment of achalasia.

　　The main symptom is dysphagia, which is intermittent in the early stage and can easily occur after excessive drinking, overeating, or eating cold and hot foods. With the progression of the disease, it can change from intermittent to persistent. One of its significant characteristics is the effort to swallow, and the time to eat each meal is significantly prolonged. 70% of patients have vomiting and regurgitation after eating; 60% of patients have sharp pain behind the sternum or under the xiphoid process unrelated to food, some occurring at night, and some occurring during swallowing, making this disease an important cause of esophageal源性 chest pain.

　　Most young and middle-aged patients, although they have difficulty swallowing and the course lasts for several years, do not have systemic effects, which is quite different from esophageal cancer patients.

　　Infants or a few patients may develop nutritional disorders, affecting growth and weight loss due to severe obstruction and severe vomiting.

　　It is recommended to eat less and more frequently, chew food carefully, avoid cold and hot foods and刺激性 foods, and for those with nervous tension, psychological treatment and external agents can be given. Some patients adopt the Valsalva maneuver to promote food from the esophagus into the stomach, relieve discomfort behind the sternum, and sublingual nitroglycerin can alleviate or relieve esophageal spastic pain, accelerate esophageal emptying.

　　First, X-ray esophageal contrast

　　The esophagus at the junction with the stomach shows a beak-like, radish root, or funnel-like sign, with the upper esophagus significantly expanded. It can be divided into three types:

　　1. Mild type

　　The esophagus is slightly expanded and there is some food retention; the gastric bubble exists;

　　2. Moderate type

　　The esophagus is widely expanded, with obvious food residue, a liquid level in an upright position, and the gastric bubble disappears;

　　3. Severe type

　　The esophagus expands, curves, widens, lengthens, and forms an S shape.

　　Secondly, esophageal motility function examination

　　Measurement of pressure shows that the resting pressure of the lower esophageal sphincter in patients is 2 to 3 times higher than that of normal people, due to the inability of the lower esophageal sphincter to relax completely, causing obstruction at the junction of the esophagus and stomach; the lower esophagus lacks normal peristalsis or peristalsis disappears, food cannot pass through the obstruction smoothly, and emptying is delayed.

　　Firstly, food therapy for achalasia

　　1. Rose petals 6 grams, clove 3 grams, silver ear 30 grams, a little sugar. Steam the silver ear for 1 hour, add rose petals, cloves, and sugar, simmer and take in several doses. Used for patients with intermittent difficulty in swallowing and food reflux.

　　2. Boil 200 milliliters of milk and eat it on an empty stomach. Once in the morning and once in the evening. Used for patients with intermittent difficulty in swallowing.

　　3. Grind 200 grams of fresh radish, boil in hot water, cool and take in several doses. Used for patients with qi stagnation and phlegm condensation.

　　4. Vinegar egg therapy: 15 grams of pinellia, 30 grams of white peony, 15 grams of vinegar, boil and remove the dregs, add one fresh egg, mix well and drink.

　　Secondly, dietary principles for achalasia

　　Eat less and more meals, chew food slowly, and avoid eating fast, cold, and spicy foods.

　　1. Generally, drugs that reduce vagal nerve activity, such as atropine, belladonna, opium alkaloids, or ergotamine, or ergotamine, are used to reduce the lower esophageal sphincter tone to relieve pain and dysphagia, but the efficacy of drug treatment is poor. Currently, mechanical dilation or surgical methods are used.

　　2. Mechanical dilation is used, and if the force is applied properly and the pressure is appropriate, good results can be obtained for cases with mild lesions. However, repeated treatment is required to maintain the efficacy.

　　Surgery is currently a relatively ideal treatment method, and the modified Heller operation is mostly used: that is, the circular muscle layer under the esophagus is longitudinally incised to the submucosa, causing the mucosa to bulge. 94% of patients experience relief from dysphagia after surgery, and 3% of patients develop reflux esophagitis after surgery.