Achalasia Cardia

Questions on Achalasia cardia

Esophagus MCQ                  Questions 6-10                         Questions 16-20

Pathological features of Achalasia Cardia
  1. Inflammation and loss of inhibitory neurons in Auerbach's plexus which secrete VIP and Nitric oxide
  2. Aperistalsis in the body of esophagus due to neuritis and ganglionitis followed by fibrosis of neurons

Wallerian degenerative changes have been described in the vagus nerve and dorsal motor nucleus of the vagus,

  1. Progressive esophageal dilatation
  2. Mucosal changes in the form of ulceration and fibrotic thickening
  3. Muscle hypertrophy also occurs

Etiological factors

  1. Genetic association with Allgrove's syndrome
  2. HLA based-  HLA DQw1 HLA DQB1
  3. Immune Association with Rheumatoid Arthriris and endocrinopathies
  4. Viral- HSV, polio.

Vigorous achalasia is defined as the presence of nonpropulsive contractions with an amplitude greater than 37 mm Hg.

Complications of Achalasia Surgery

  1. Persistent Dysphagia- Inadequate myotomy

The study done to find out completeness of Myotomy is timed barium study. A timed barium study compares the height of a barium column in the esophagus at 1 and 5 minutes after the patient drinks 250 cc of liquid barium within 45 seconds. In most patients who have untreated achalasia there is minimal (5%–10%) emptying over this time period . After successful myotomy there commonly is complete (90%–100%) emptying by the 5-minute film.

  1. Site of myotomy

The best location for a myotomy would seem to be on the left side of the esophagus extending down across the angle of His onto the fundus of the stomach. A myotomy in this location would disrupt the longitudinal and circular muscular fibers of the esophagus as well as the oblique gastric fibers while preserving the clasp fibers along the lesser curve side of the stomach.

  1. Post myotomy stricture or scarring

Inadequate separation of muscle fibres

  1. Post op leak
  2. Post op GERD


11. Which is not a recommended procedure for carcinoma esophagus  in the thoracic cavity
A) McKeown approach
b) Lewis Tanner approach
c) Transhiatal esophagectomy
d) Single right thoracotomy incision
12. In Achalasia cardia all are possible etiological theories except
a) Trauma
b) Drastic weight loss
c) Emotional stress
d) Epiphrenic diverticulum
13. Not true about the etiology of Achalasia cardia
a) It is a familial disease
b) Allgrove's disease is a rare condition associated with achalasia
c) HSV-1, HSV-2, Polio virus
d) Assciation with class II MHC antigen
14. True about the role of medical therapy in Barrett's Esophagus
a) There is direct evidence that medical treatment prevents development of Barrett's esophagus in patients with GERD
b) The end point of treatment in Barrett's esophagus  is control of reflux
c) COX 2 inhibitors have a role in prevention of Adenocarcinoma in patients with Barrett's Esophagus
15. One of the following is not a hallmark  of end stage Achalasia Cardia
a) Severe dysphagia or regurgitation
b) Hypertensive Lower esophageal sphincter tone
c) Mega esophagus or sigmoid esophagus
d) Reduction of ganglion cells  with fibrosis of Myenteric plexus
For tumors in the upper thoracic esophagus, obtaining a sufficient proximal resection margin dictates an anastomosis placed in the neck.
McKeown approach--- In this procedure a right thoracotomy is first carried out to mobilize the thoracic  (Further reading Premium members only)