Achalasia

Condition

• Achalasia 

Definition 

• failure for smooth muscle to relax, which can cause a sphincter to remain closed and fail to open when needed.

Main features

• Gradual onset of dysphagia for both liquids and solids 
• Fluctuating symptoms 

Investigations

• Diagnosis confirmed by barium swallow or manometry 

Treatment 

• Attacks are often triggered by GORD, so treatment for GORD is sometimes helpful
• Ingestion of warm water at the commencement of an attack can be helpful
• GTN spray may shorten an attack 
• If attacks are frequent and disabling, try:
• Diltiazem controlled release 180 mg orally, once daily, increasing 240 to 360 mg orally, once daily depending on response and adverse effects
• isosorbide dinitrate 10 to 20 mg orally, 3-4 times daily 
• Nifedipine controlled release 20 to 30 mg orally, once daily, increasing to 60 mg orally, once daily depending on response and adverse effects
• Refractory symptoms may require : injecting botulinum toxin type A into the lower oesophageal sphincter or myotomy of the lower oesophagus

References:

• John Murtagh's general practice 5th edition 
• eTG