Achalasia

　　The etiology of this disease is still unclear, and it may be related to genetic inheritance, autoimmune disorders, viral infection, and psychological and social factors. Its main pathological changes are the degeneration, reduction, and even disappearance of ganglia in the esophageal muscle layer, which can affect the entire thoracic esophagus, but is most obvious in the middle and lower segments of the esophagus. Due to the high pressure of the lower esophageal sphincter and the inability to relax during swallowing, the esophageal peristalsis is weak, and food entering the stomach is blocked, causing food to be retained in the esophagus. Over time, the esophagus expands, elongates, bends at an angle, and loses muscle tone. The retention of food stimulates the esophageal mucosa, causing inflammation, followed by ulcers. Cancer can occur on the basis of long-term chronic inflammation.

　　Dysphagia is the most common symptom, most patients have vomiting, and in the early stage of the disease, the amount of vomit is small, just food entered without acid taste. With the progression of the disease, the esophageal capacity increases, the frequency of vomiting may decrease, but the vomit is often undigested foul-smelling food.

　　This disease is slightly more common in females than in males, and the age can range from infants to over 80 years old, mainly occurring in young and middle-aged people aged 20 to 50. Surgical treatment can effectively relieve dysphagia and achieve satisfactory efficacy.

　　The complications of achalasia mainly include respiratory lesions, esophageal cancer, esophagitis, and some other systemic diseases.

　　1. Respiratory complications occur in about 10% of patients, more明显 in children, mainly due to aspiration pneumonia, bronchiectasis, lung abscess, and pulmonary fibrosis caused by aspiration of non-tuberculous mycobacteria and oil retained in the esophagus, which 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 non-tuberculous mycobacteria, and should not be mistaken for tubercle bacilli. There are three mechanisms that can cause respiratory complications: ① Ingestion of food content into the trachea or bronchus, most frequently occurring in patients with dilated esophagus, especially during nocturnal supine position, repeated small amounts of aspiration, accompanied by symptoms such as cough, wheezing, and shortness of breath; ② Significant dilation and filling of the esophagus cause tracheal compression, making breathing and expectoration unsmooth; ③ The occurrence of fistula between the esophagus and trachea, or left bronchus, due to concurrent cancer can cause severe respiratory symptoms. Among them, the first item is the most common.

　　2. Esophageal cancer is reported to occur in 2% to 7% of patients, especially in those with a disease course of more than 10 years, with significant esophageal dilation and severe retention. The main cause is chronic inflammation caused by the irritant factors of esophagitis due to food retention. The incision or dilation of the esophageal muscle layer after surgery cannot prevent the occurrence of cancer, and there are reports of cancer occurring many years after successful surgery. Therefore, careful observation should be made for the occurrence of esophageal cancer, and a biopsy should be performed when suspicious conditions are encountered. Huang Guojun and Zhang Wei reported that the incidence of gender in achalasia patients with esophageal cancer is similar to that of esophageal cancer, mainly male, but the onset age of cancer complicated with achalasia is younger than that of esophageal cancer patients. The average age of patients with achalasia is 48 to 51 years, and that of patients without achalasia is 62 to 67 years. Tumors are most commonly found in the middle segment of the esophagus, followed by the lower and upper segments. Diagnosis is often delayed, as the gastrointestinal symptoms of the patient are often mistaken for achalasia, and only when the tumor grows to a larger size and blocks the dilated esophagus does attention be paid. Symptoms include weight loss, difficulty swallowing from intermittent to progressive, and the appearance of blood-stained material or anemia before discovery. In cases suspected of having 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 of achalasia, endoscopic examination can see esophagitis and mucosal ulcers caused by it, ulcers can cause bleeding, a few spontaneous perforations occur, and esophagotracheal fistula. Patients with body weakness or those who have received antibiotic treatment or granulocytopenia may be complicated with candidal infection. White spots are seen on the inflammatory mucosa in endoscopy. Specimen smears and biopsies can be used for diagnosis.

　　4. Other complications. Due to the esophageal dilation of achalasia, the intraluminal tension increases, leading to the complication of diaphragmatic hernia diverticula, which can be treated at the same time as the treatment for achalasia. A few patients may have joint complications similar to rheumatoid arthritis, and the symptoms can be relieved after the treatment of achalasia.

　　1. Progressive dysphagia, developing slowly.

　　2. Food regurgitation is more obvious when lying down, about 1/3 of patients occur at night, and can cause aspiration pneumonia, lung abscess.

　　3. Chest pain is a common early complaint in the course of the disease, of varying nature, may be discomfort or pain behind the sternum or upper abdomen, may radiate to the precordial area, neck, and upper limbs. Sometimes it is similar to angina, and after sublingual nitroglycerin tablets, it can also be relieved.

　　4. Weight loss, mild to moderate decrease.

　　5. Extremely dilated esophagus may cause dry cough, dyspnea, cyanosis, and hoarseness due to compression of intrathoracic organs.

　　Achalasia prevention can be started from the following aspects:

　　1. Change of bad eating habits, not eating moldy food, eating less or not eating pickled vegetables.

　　2. Improvement of water quality, reduction of nitrite content in drinking water.

　　3. Promotion of trace element fertilizers, correction of soil deficiency in trace elements such as molybdenum.

　　4. Use of Chinese and Western medicine and vitamin B2 to treat esophageal epithelial hyperplasia to block the carcinogenic process. Actively treat diseases related to esophagitis, esophageal leukoplakia, achalasia of the cardia, esophageal diverticula, and other diseases.

　　5. Surveillance of susceptible populations, popularization of cancer prevention knowledge, and enhancement of cancer prevention awareness.

　　The above-mentioned are the preventive methods for achalasia of the cardia, high-risk areas and high-risk populations should pay more attention, actively prevent the disease, and in case of symptoms, they should seek timely diagnosis and treatment in regular hospitals.

　　1. X-ray Examination In chest X-ray films, sometimes it is possible to see an expanded esophagus, disappearance of air bubbles in the stomach, changes in lung fields in the presence of pneumonia or lung abscess, with the most common being the disappearance of stomach air bubbles. The esophagus with marked dilation expands towards the mediastinum in the anteroposterior chest film, and sometimes a liquid level can be seen. In the lateral film, the trachea can be seen to be anteriorly displaced, and in early cases, no abnormalities may appear during X-ray examination.

　　2. Barium Meal Examination Barium esophagram is an important diagnostic examination in achalasia cases, characterized by the disappearance of esophageal peristalsis, loss of relaxation response of the distal sphincter during swallowing, retention of barium at the gastroesophageal junction, smooth wall of this part, and sudden narrowing into a beak-like change.

　　3. Endoscopic examination The lower end of the esophagus and the cardiac orifice are persistently closed without opening, with retained liquid or food in the esophagus, the esophageal lumen is dilated, in severe cases, the esophageal lumen dilates like the gastric cavity, occasionally the course of the esophagus is twisted into an S shape, and the esophageal wall may sometimes be seen with a wheel-like contraction ring, and it is often not visible to the primary or secondary propulsive contractions. Due to the dilation and twist of the esophagus, it becomes longer, and the distance from the incisors to the cardiac orifice often exceeds 40cm, the lower end of the esophagus and the cardiac orifice remain persistently closed, and even after inflation, they do not open, and the endoscope passes through with resistance, generally a slight effort can enter the gastric cavity. The mucosa of the esophagus is often accompanied by retention inflammatory changes, which are more obvious in the lower part, showing erosion and superficial ulcers.

　　4. Methacholine (mecholyl) test In normal individuals, 5-10mg of methacholine is injected subcutaneously, which increases esophageal peristalsis without significant pressure increase. However, in patients with this disease, strong esophageal contractions can be produced within 1-2 minutes after injection; the esophageal pressure increases abruptly, causing severe pain and vomiting, and the X-ray signs become more pronounced (atropine should be prepared in case of severe reaction). The esophagus is extremely dilated and does not respond to this drug, resulting in a negative test result; in patients with gastric cancer involving the esophageal wall intermuscular plexus, and some with diffuse esophageal spasm, this test can also be positive.

　　Due to the long course of the disease, the patient has difficulty eating for a long time, and is often in a state of hunger. Provide easily digestible, high-calorie, and nutrient-rich liquid or semi-liquid diets. Eat in small and frequent meals, 1 meal every 2-3 hours, 200ml per meal, avoid cold or hot food temperatures, pay attention to chew slowly, and reduce the stimulation of food to the esophagus. For those with excessive food retention or severe regurgitation, appropriate fasting for 1-3 days may be required, and necessary calories, water, electrolytes, vitamins, etc., should be provided via intravenous infusion. After adjusting and treating the symptoms, gradually resume eating. Avoid sour, spicy, fried, and cold foods, and refrain from smoking and drinking.

　　After surgery for achalasia, avoid eating cold, hot, and刺激性 foods. Instruct the patient to eat less and more frequently, consume liquid or semi-liquid diets, and avoid lying down for 1-2 hours after meals.

　　Achalasia food therapy includes:

　　① 6 grams of rose petal, 3 grams of clove bud, 30 grams of silver ear, a little sugar. Steam the silver ear for 1 hour, add the rose petal, clove bud, and sugar, simmer slightly, and take in divided doses. Used for intermittent difficulty in swallowing and food regurgitation.

　　② 200 milliliters of milk, boiled and consumed on an empty stomach. Once in the morning and once in the evening. Used for intermittent difficulty in swallowing.

　　③ 200 grams of raw radish, pounded into juice, scalded with boiling water and then cooled, taken in divided doses warm. Used for qi stagnation and phlegm congestion.

　　④ Egg vinegar therapy: 15 grams of pinellia, 30 grams of white peony root, 15 grams of vinegar, boil and remove the residue, add 1 fresh egg, stir well and drink.

　　Conventional methods of Western medicine for the treatment of achalasia.

　　1. General treatment. Eat less and more frequently, chew slowly while eating, and avoid eating too fast or consuming cold and stimulating foods. Drinking water helps with eating. Relieve mental tension, and provide psychological treatment and sedatives when necessary. Due to the highly dilated esophagus with a large amount of retained food, fasting or aspiration may be required to empty the esophagus.

　　2. Drug Treatment. Mainly include nitroglycerin preparations, calcium channel blockers, cholinergic antagonists, acid inhibitors, and mucosal protective drugs.

　　a) Nitroglycerin preparations: Oral or sublingual nitroglycerin (0.6mg, 3-4 times a day, 3-5 minutes before meals) can directly relax the LES, improve dysphagia and chest pain. Nitroglycerin isosorbide (Isordil, 5mg-10mg, 3-4 times a day) can also be selected.

　　b) Calcium channel blockers: Nifedipine (Nifedipine, 10mg, 3 times a day) relaxes the LES.

　　c) Cholinergic antagonists: The main mechanism of action is to relax smooth muscle and promote food emptying. When there is obvious food retention, intramuscular injection of the cholinergic antagonist butylbromide atropine (spasmolytic, 10-20mg/time) can temporarily relieve symptoms. If reflux occurs, antacids or mucosal protective drugs can be given. Drug treatment is suitable for the early stage of the disease when the esophagus has not yet expanded or for elderly patients who cannot tolerate interventional or surgical treatment.

　　3. Interventional Treatment. (1) Botulinum toxin injection therapy: Inject botulinum toxin at different locations in the LES region under esophagoscopy, and relax the muscle by blocking the release of acetylcholine at the synaptic junction of the esophageal sphincter muscle through the toxin, thereby alleviating symptoms. (2) Physical dilation therapy: Esophageal dilation can be applied with a balloon, water balloon, or probe, dilating the LES area, which can alleviate symptoms.

　　4. Placement of a dilator under esophagoscopy. Using an esophagoscope to place a small dilator into the esophagus-cardia area, slowly dilate the circular muscle at this location, and use the elasticity of the dilator to keep the sphincter dilated, relieve the spasm of the sphincter, achieve a relaxed state, and restore its function. The advantages are to avoid surgical operation, less pain, rapid efficacy, no perforation, and no complications of esophageal reflux, which is a new effective method for treating esophageal-cardia achalasia.

　　5. Surgical Treatment. If drug or dilation treatment does not achieve satisfactory efficacy, and the patient's symptoms are still obvious, and there are no surgical contraindications, surgical treatment can be considered. The commonly used procedures are Heller's operation, which involves incising the submucosal muscle layer of the esophagus through an abdominal or thoracic large incision, and attention should be paid to combining anti-reflux surgery.