Achalasia Cardiae

Note: The word "dilation" means to get larger. If the esophagus muscle at the juncture of the esophagus and the stomach "stays open" (or stays dilated) or "is open," then food can pass through the esophagus into the stomach and there would be no swallowing problem. The article below seems to use the word "dilation" in two quite opposite meanings -- once to mean open and once to mean closed. The act of this muscle "staying closed" could be called a "spasm." Normally a "spasm" is defined as: "A sudden, involuntary contraction of a muscle or group of muscles. " In the article below the term "dilation" appears to be used to mean that the muscle is closed (not open), the same word is also used to mean "open." The word "dysphagia" means, "Difficulty in swallowing or inability to swallow. Also called aglutition, aphagia, odynophagia. The phrase below: Achalasia is a motility disorder of the oesophagus, where there is a nerve degeneration in the Auerbachs plexus, causing inability of the lower oesophageal sphincter in the cardia region (C) to relax. means, or can be reworded as: This "disease" of the esophagus is caused by a nerve problem so that the muscle at the end of esophagus is not able to open up. It is "in spasm." Thus, there is "trouble swallowing."

However, more careful reading of this article suggests that the "closing" is related to the sphincter muscle (a spasm) and the "opening" referred to is in the remainder of the esophagus -- a dilation. The dilation of the esophagus, itself, in this case, is caused by food lodging in the esophagus and not being able to pass through the sphincter muscle -- yet the endoscope CAN pass through that sphincter muscle, so the source of the swallowing problem can be hidden from the investigator. This article, then, is pointing out that if the esophagus, itself, is dilated (larger than normal) there may be a problem with the sphincter muscle, even though the endoscope can pass through that opening into the stomach.

Achalasia Cardiae
Achalasia is a motility disorder of the oesophagus, where there is a nerve degeneration in the Auerbachs plexus, causing inability of the lower oesophageal sphincter in the cardia region (C) to relax. In oesophageal x-ray examinations a dilatation of the oesophagus is seen, and the contrast stays in the oesophagus for a long time. Endoscopy is important in order to exclude other causes of dysphagia. Endoscopic examination often shows a quite normal cardia, and in less severe cases the endoscopic diagnose is not easy. A constant spasm just above the cardia region can be visualized but the passage of the endoscope into the stomach is usually not difficult. These pictures are from a patient with dysphagia for about two years, causing a weight loss of over 40 pounds. In advanced cases (which this is not), the dilatation of the oesophagus is quite marked.

One year later, when the symptom where somewhat relieved by dilatations, the oesophagus is still slightly dilated.

Note: It is the esophagus that is dilated here, not the sphincter muscle. Chagasdisease is an important differential diagnosis. This disease is caused by an infection with Trypanosoma cruzi and in this disease, the symptoms and x-ray findings are identical with classic achalasia. Chagasdisease is common in some countries in Latin America.

Still one year later, the symptoms has worsened, and the patient is still losing weight. These pictures show a seriously dilated oesophagus with a very slow transit through the cardia region. Note: This means that the esophagus, itself, is dilated open, larger than normal because food lodges there and cannot pass through the contracted sphincter muscle at the end of the esophagus. The picture to the left is taken in a standing position, in the picture to the right the patient is lying down. In endoscopy, the oesophagus is filled with food in an advanced case like this. A situation like this could be treated by repeated dilatations or by surgical laparoscopic cardiomyotomy.

Oesophagus just above the cardia in a patient with achalasia. This image are taken during inspection of this region for several minutes.

Spasm Sphincter
Spasm Sphincter a circular muscle that constricts a passage or closes a natural orifice. When relaxed, a sphincter allows materials to pass through the opening. When contracted, it closes the opening. There are four main sphincter muscles along the alimentary canal that aid in digestion: The cardiac sphincter, between the esophagus and the stomach, opens at the approach of food, which is then swept into the stomach by rhythmic peristaltic waves. The pyloric sphincter controls the opening from the stomach into the duodenum. It is usually closed, opening only for a moment when a peristaltic wave passes over it. Two anal sphincters, internal and external, control the anus, allowing the evacuation of feces. In addition, there are sphincters in the iris of the eye, the bile duct (sphincter of Oddi), the urinary tract, and elsewhere in the body. .

What is esophageal spasm? Esophageal spasms are irregular, uncoordinated, and sometimes powerful contractions of the esophagus, the tube that carries food from the mouth to the stomach. Normally, contractions of the esophagus are coordinated, moving the food through the esophagus and into the stomach. Esophageal spasms can prevent food from reaching the stomach, leaving it stuck in the esophagus. Esophageal spasms are rare. Often, symptoms that may suggest an esophageal spasm are the result of another condition such as gastroesophageal reflux disease (GERD) or achalasia, a problem with the nervous system in which the lower esophageal sphincter (LES) doesn't work properly. Anxiety or panic attacks can also cause similar symptoms. What causes esophageal spasm? The cause of esophageal spasm is unknown. Many doctors believe it results from a disruption of the nerve activity that coordinates the swallowing action of the esophagus. In some people, very hot or very cold foods may trigger an episode. What are the symptoms? Most people with this condition have chest pain that may spread outward to the arms, back, neck, or jaw. This pain can feel similar to a heart attack. If you have chest pain, you should be evaluated by a health professional as soon as possible to rule out or treat cardiac disease. Other symptoms include difficulty or inability to swallow food or liquid, pain with swallowing, the feeling that food is caught in the center of the chest, and a burning sensation in the chest (heartburn).

How is esophageal spasm diagnosed? Your doctor can often determine the cause of esophageal spasm by doing a physical exam and asking you a series of questions. These include questions about what foods or liquids trigger symptoms, where it feels like food gets stuck, other symptoms or conditions you may have, and whether you are taking medications for them. The diagnosis can be confirmed with tests, including a barium swallow or endoscopy. These tests use X-rays or a small, lighted viewing instrument to examine the inside of the esophagus. Your health professional may also do esophagus testing, a set of tests used to evaluate the condition and function of the esophagus. Tests measure acid levels in the esophagus as well as the strength and pattern of muscle contractions in the esophagus. Other tests may be done to determine whether chest pain may be caused by gastroesophageal reflux disease (GERD), the abnormal backflow (reflux) of food, stomach acid, and other digestive juices from the stomach into the esophagus. How is it treated? Treatment for esophageal spasm includes treating other conditions that may make esophageal spasms worse, such as gastroesophageal reflux disease (GERD). GERD is usually treated with changes to diet and lifestyle and medications to reduce the amount of acid in the stomach. Medications such as nitrates and calcium channel blockers may also be given to relax the muscles of the esophagus, though they are not always effective. Botulinum toxin (Botox) is also being used to treat esophageal spasm. Botulinum toxin is a poison produced by the bacteria that cause botulism. When injected into the esophageal musclesusually during an upper endoscopyit blocks the function of the nerves in those muscles, preventing spasms. Swallowing peppermint oil mixed with water may make the muscles of the esophagus contract regularly. 1 Treating anxiety with relaxation and controlled breathing exercises may also help to reduce symptoms. 2 Rarely, surgery is used to treat esophageal spasm. The surgeon cuts the muscles along the lower esophagus. This procedure is usually performed only in serious cases that do not respond to other therapies. Top

Staging is the process of finding out whether the cancer has spread and if so, how far. The treatment and prognosis (the outlook for chances of survival) for people with esophageal cancer depend, to a great extent, on the cancer's stage. Eophageal cancer can be staged in several ways but symptoms such as dysphagia most commonly lead to a barium swallow and/or endoscopy

procedure. The size of the tumor can then be estimated. Then a CT scan is usually done, especially if the tumor is smaller than 5 centimeters (2 inches). The CT scan can show if the cancer has spread to nearby lymph nodes and/or the lungs, if the tumor extends through the esophagus into the trachea (windpipe), and if the cancer has spread to distant organs like the liver.
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In some medical centers, endoscopic ultrasound can be performed to give very detailed pictures of just how deeply the cancer has invaded the esophageal tissue. The depth of penetration of the cancer is very important in determining the chances for at least a 5-year survival as well as whether surgery is likely to help the patient. The most common system used to stage esophageal cancer is the TNM system of the American Joint Committee on Cancer (AJCC). The TNM system describes 3 key pieces of information. T refers to the size of the primary tumor and how far it has spread within the esophagus and to nearby organs. N refers to cancer spread to nearby lymph nodes. M indicates whether the cancer has metastasized (spread to distant organs). T Stages
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TX: primary tumor cannot be assessed T0: no evidence of primary tumor Tis: carcinoma in situ (the tumor has not invaded beyond the epithelium, the first or innermost layer of the esophagus) T1: tumor invades the lamina propria (second layer) or submucosa (third layer) T2: tumor invades the muscularis propria (fourth layer) T3: tumor invades the adventitia (fifth and outermost layer) T4: tumor invades nearby structures N Stages

NX: nearby lymph nodes cannot be assessed N0: no spread to nearby lymph nodes
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N1: spread to nearby lymph nodes M Stages MX: spread to other organs cannot be assessed M0: no spread to distant organs M1: spread to distant organs Information about the tumor, lymph nodes, and metastasis is then combined to assign a stage of disease. This process is called stage grouping. The stages are described using the number 0 and Roman numerals from I to IV:

Stage 0 Stage I Stage IIA Stage IIB Stage III Stage IV

Tis T1 T2 or T3 T1 or T2 T3 T4 Any T

N0 N0 N0 N1 N1 Any N Any N

M0 M0 M0 M0 M0 M0 M1

Stage 0: This is the earliest stage of esophageal cancer. This stage is also called carcinoma in situ, meaning that cancer cells are limited to the epithelium (the part of the mucosa forming the inner lining of the esophagus). The cancer does not invade the connective tissue beneath the epithelium. The cancer has not spread to lymph nodes or other organs.
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Stage I: Stage I means that the esophageal cancer has invaded from the epithelium into some of the other layers of the esophagus. Cancer may be present in the lamina propria, the connective tissue part of the

mucosa, or the submucosa, the connective tissue underneath the mucosa. The cancer has not spread to the muscularis propria, the thick muscle layer of the esophagus that pushes food from the throat into the stomach. In this stage, the cancer has not spread to lymph nodes or to any other organs. Stage II: There are 2 substages IIA and IIB. Stage IIA: In this stage, the cancer has invaded the muscularis propria and may extend through that layer into the adventitia, the connective tissue covering the outside of the esophagus. The cancer has not spread to lymph nodes or to any other organs. Stage IIB: The cancer may invade the lamina propria, submucosa, and the muscularis propria, but not the adventitia. However, it has spread to lymph nodes near the esophagus. Other organs are not involved. Stage III: Cancers in this stage have either spread to the adventitia and to lymph nodes near the esophagus or they have spread beyond the adventitia into nearby organs, such as the trachea (windpipe), and may or may not have spread to the lymph nodes. The cancer has not spread to lymph nodes farther away from the esophagus (such as nodes in the neck or nodes in the lower abdomen). It has not spread through the bloodstream to organs farther away from the esophagus (such as the liver, bones, or brain).
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Stage IV: This stage indicates that the esophageal cancer has spread to distant organs. Spread through the bloodstream to organs away from the esophagus (such as the liver, bones, or brain) is always considered distant spread. Depending on the exact location of the primary cancer in the esophagus, spread to nonregional (not next to the esophagus) lymph nodes may also be considered distant spread. If the esophageal cancer is in the upper part of the chest, spread to lymph nodes in the abdomen near the stomach is considered distant spread. For cancers of the lower part of the esophagus, spread to lymph nodes near the neck is considered distant spread. Survival Rates by Stage Stage 5-year survival rate (surviving at least 5 years)

75%

I IIA IIB III IV

60% 40% 20% 15% less than 5%

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These survival rates are an average of outcomes of patients with the same stage. They do not take into account differences in treatment or a patient's general state of health. These are provided as estimates only and the outlook for any individual patient may differ from these average figures. . In addition, these rates are based on past cases. Recent treatment advances may offer options for people with esophageal cancer today that past patients did not have.
Esophageal spasm Source: A.D.A.M., Inc. Updated: May 2005 Definition Esophageal spasms involve irregular contractions of the muscles in the esophagus, which is the tube that carries food from the mouth to the stomach. These spasms do not propel food effectively to the stomach. Causes, incidence, and risk factors The cause of esophageal spasm is unknown. Very hot or very cold foods may trigger an episode in some people. The pain may be indistinguishable Throat from angina and may radiate to the neck, jaw, arms, or back. anatomy Symptoms

Digestive system

Difficulty swallowing or pain with swallowing Heartburn Pain in the chest or upper abdomen

Signs and tests An esophagogram shows irregular contractions of the esophagus. Esophageal manometry shows esophageal spasms. Treatment Sublingual (beneath the tongue) nitroglycerin may be effective in an acute episode. Long-acting nitroglycerin and calcium channel blockers are also used to treat esophageal spasms. Chronic cases are sometimes treated with low-dose antidepressants such as nortryptiline, to reduce symptoms. Rarely, severe cases require surgery. Expectations (prognosis) An esophageal spasm may be an intermittent or chronic condition. Relief of symptoms is usually achieved with medication. Complications The condition may not respond to treatment. Calling your health care provider Call for an appointment with your health care provider if you have persistent esophageal spasm symptoms. Prevention Avoid very hot or very cold foods if you are prone to esophageal spasms. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -they do not constitute endorsements of those other sites. Copyright 2005 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.