A report on Esophageal achalasia

A chest X-ray showing achalasia ( arrows point to the outline of the massively dilated esophagus )
Transhiatal oesophagectomy specimen from a patient suffering from late-stage achalasia. Diverticulum at the left lower end of the oesophagus.
An axial CT image showing marked dilatation of the esophagus in a person with achalasia.
"Bird's beak" appearance and "megaesophagus", typical in achalasia.
Schematic of manometry in achalasia showing aperistaltic contractions, increased intraesophageal pressure, and failure of relaxation of the lower esophageal sphincter.
Image of a stomach which has undergone Fundoplomy

Failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed.

- Esophageal achalasia
A chest X-ray showing achalasia ( arrows point to the outline of the massively dilated esophagus )

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Overall

The digestive tract, with the esophagus marked in red

Esophagus

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Organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the stomach.

Organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the stomach.

The digestive tract, with the esophagus marked in red
The esophagus is constricted in three places.
A mass seen during an endoscopy and an ultrasound of the mass conducted during the endoscopy session.

Achalasia refers to a failure of the lower esophageal sphincter to relax properly, and generally develops later in life.

The digestive tract, with the esophagus marked in red

Dysphagia

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Difficulty in swallowing.

Difficulty in swallowing.

The digestive tract, with the esophagus marked in red

Achalasia is a major exception to usual pattern of dysphagia in that swallowing of fluid tends to cause more difficulty than swallowing solids.

Diagram of esophageal motility study in 'nutcracker esophagus'. The disorder shows peristalsis with high pressure esophageal contractions exceeding 180 mmHg and contractile waves with a long duration exceeding 6 seconds.

Esophageal motility study

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Test to assess motor function of the upper esophageal sphincter (UES), esophageal body and lower esophageal sphincter (LES).

Test to assess motor function of the upper esophageal sphincter (UES), esophageal body and lower esophageal sphincter (LES).

Diagram of esophageal motility study in 'nutcracker esophagus'. The disorder shows peristalsis with high pressure esophageal contractions exceeding 180 mmHg and contractile waves with a long duration exceeding 6 seconds.

These include achalasia, diffuse esophageal spasm, nutcracker esophagus and hypertensive lower esophageal sphincter.

Potential location of pain from a heart attack

Chest pain

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Pain or discomfort in the chest, typically the front of the chest.

Pain or discomfort in the chest, typically the front of the chest.

Potential location of pain from a heart attack
A blockage of coronary arteries can lead to a heart attack
Gastroesophageal reflux disease is a common cause of chest pain in adults

Achalasia, nutcracker esophagus, and other motility disorders of the esophagus

Barium meal examination showing the stomach and duodenum in double contrast technique with CO2 as negative contrast medium

Upper gastrointestinal series

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Series of radiographs used to examine the gastrointestinal tract for abnormalities.

Series of radiographs used to examine the gastrointestinal tract for abnormalities.

Barium meal examination showing the stomach and duodenum in double contrast technique with CO2 as negative contrast medium
Barium follow through showing the small bowel
Enteroclysis in double contrast technique showing stenosis of the small intestine
Zenker's diverticulum as seen in a barium swallow examination
Barium in the lungs resulting from aspiration during a barium swallow

Amongst the uses of barium swallow are: persistent dysphagia and odynophagia despite negative esophagogastroduodenoscopy (OGDS) findings, failed OGDS, esophageal motility disorder, globus pharyngis, assessment of tracheoesophageal fistula, and timed barium swallow to monitor the progress of esophageal achalasia therapy.

Normal peristalsis in time space graph. Nutcracker esophagus shows higher amplitude contractions (Z-axis) that take longer to pass (X-axis)

Nutcracker esophagus

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Disorder of the movement of the esophagus characterized by contractions in the smooth muscle of the esophagus in a normal sequence but at an excessive amplitude or duration.

Disorder of the movement of the esophagus characterized by contractions in the smooth muscle of the esophagus in a normal sequence but at an excessive amplitude or duration.

Normal peristalsis in time space graph. Nutcracker esophagus shows higher amplitude contractions (Z-axis) that take longer to pass (X-axis)
Diagram of esophageal motility study in nutcracker esophagus: The disorder shows peristalsis with high-pressure esophageal contractions exceeding 180 mmHg and contractile waves with a long duration exceeding 6 sec.
Normal esophagus in (A). Nutcracker esophagus in (C): high-pressure waves in blue; cross-sectional areas (CSA) in fucsia.

Nutcracker esophagus is one of several motility disorders of the esophagus, including achalasia and diffuse esophageal spasm.

Endoscopic image of an esophageal adenocarcinoma

Esophageal cancer

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Cancer arising from the esophagus—the food pipe that runs between the throat and the stomach.

Cancer arising from the esophagus—the food pipe that runs between the throat and the stomach.

Endoscopic image of an esophageal adenocarcinoma
Esophageal cancer (lower part) as a result of Barrettʼs esophagus
Esophageal cancer as shown by a filling defect during an upper GI series
Esophageal stent for esophageal cancer
Esophageal stent for esophageal cancer
Before and after a total esophagectomy
Typical scar lines after the two main methods of surgery
Death from esophageal cancer per million persons in 2012
Endoscopic image of Barrett esophagus – a frequent precursor of esophageal adenocarcinoma
Endoscopy and radial endoscopic ultrasound images of a submucosal tumor in the central portion of the esophagus
Contrast CT scan showing an esophageal tumor (axial view)
Contrast CT scan showing an esophageal tumor (coronal view)
Esophageal cancer
Micrograph showing histopathological appearance of an esophageal adenocarcinoma (dark blue – upper-left of image) and normal squamous epithelium (upper-right of image) at H&E staining
T1, T2, and T3 stages of esophageal cancer
Stage T4 esophageal cancer
Esophageal cancer with spread to lymph nodes
Internal radiotherapy for esophageal cancer
Self-expandable metallic stents are sometimes used for palliative care

Achalasia (i.e. lack of the involuntary reflex in the esophagus after swallowing) appears to be a risk factor for both main types of esophageal cancer, at least in men, due to stagnation of trapped food and drink.

Surgical removal of the esophagus.

Esophagectomy

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Surgical removal of all or parts of the esophagus.

Surgical removal of all or parts of the esophagus.

Surgical removal of the esophagus.
Diagram showing before and after an oesophago-gastrectomy
Diagram showing before and after a partial oesophagectomy
Diagram showing before and after a total oesophagectomy
An esophagectomy using the bowel (colon) to replace the esophagus

Esophagectomy is also occasionally performed for benign disease such as esophageal atresia in children, achalasia, or caustic injury.

Chagas megaseophagus

Megaesophagus

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Disorder of the esophagus in humans and other mammals, whereby the esophagus becomes abnormally enlarged.

Disorder of the esophagus in humans and other mammals, whereby the esophagus becomes abnormally enlarged.

Chagas megaseophagus
An x-ray of the thorax of a dog with megaoesophagus. The edges of the esophagus are shown by the yellow arrows. (In this image, the head end of the dog is to the right, and the tail end is to the left
The apparatus for management of the dog's megaesophagus can be simply made from a regular chair turned upside down. Some soft material to protect the back and chest of the dog may be used.

Megaesophagus may occur secondary to diseases such as achalasia or Chagas disease.

A drawing of a hiatal hernia

Hiatal hernia

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Type of hernia in which abdominal organs slip through the diaphragm into the middle compartment of the chest.

Type of hernia in which abdominal organs slip through the diaphragm into the middle compartment of the chest.

A drawing of a hiatal hernia
Schematic diagram of different types of hiatus hernia. Green is the esophagus, red is the stomach, purple is the diaphragm, blue is the HIS-angle. A is the normal anatomy, B is a pre-stage, C is a sliding hiatal hernia, and D is a paraesophageal (rolling) type.
A large hiatal hernia on chest X-ray marked by open arrows in contrast to the heart borders marked by closed arrows
This hiatal hernia is mainly identified by an air-fluid level (labeled with arrows).
Upper GI endoscopy depicting hiatal hernia
Upper GI endoscopy in retroflexion showing Type I hiatal hernia
A hiatal hernia as seen on CT
A large hiatal hernia as seen on CT imaging
A large hiatal hernia as seen on CT imaging

Meanwhile, manometry can determine the integrity of esophageal movements, and the presence of esophageal achalasia.