achalasia

ACHALASIA

a lack of relaxation of the LES with swallowing

A relative obstruction at the level of the sphincter is made worse by a lack of peristaltic waves in the esophagus

the condition affects primarily adolescents and adults children under the age 4 yr comprise fewer than 5% patients

Clinical Manifestations

difficulty in swallowing

regurgitation of food

cough from overflow of fluids into the trachea failure to gain weight

Diagnosis

roentgenogram and is confirmed with manometry

TreatmentTreatment

Dilating the cardio esophageal junction with a mercury bougie Transient relief of symptoms

TreatmentTreatment

Heller procedure

surgical division of muscles at the cardioesophageal junction

permanent relief of symptoms

GASTROESOPHAGEAL REFLUX

(CHALASIA)

The term chalasia describes the free reflux across a dilated sphincter

When the LES is not competent, excessive and passive reflux of gastric contents may cause significant symptoms

EtiologyEtiology

reflux may occur with increased intra abdominal pressure

The small reservoir capacity of the infant’s esophagus predisposes to vomiting

Placement of the gastrostomy tube encourages reflux

Mehtylxantines may exacerbate reflux by lowering sphincter tone

Clinical ManifestationsClinical Manifestations

signs and symptoms relate directly to the exposure of the esophageal epithelium to refluxed gastric contentsIn 85% of affected infants excessive vomiting occurs during the 1st week of life an additional 10% have symptoms by 6wk Patients with cerebral palsy, Down syndrome and other causes of developmental delay have an increase incidence of reflux

Clinical ManifestationsClinical Manifestations

delayed gastric emptying

forceful vomiting

aspiration pneumonia

chronic cough wheezing, clubbing and recurrent pneumonia

failure to grow and gain weight

hemorrhage and/or hematemesis

anorexia

DiagnosisDiagnosis

In mild cases, a careful clinical assessment may be sufficient for diagnosis

barium esophagography under fluoroscopic control

DiagnosisDiagnosis

esophagoscopy with biopsy

TreatmentTreatment

In mild uncomplicated cases In mild uncomplicated cases

keeping the child prone with head elevated at 20-30 degrees

thickening the feeding with cereal

careful attention to burping

TreatmentTreatment

In severe cases In severe cases

antacids or cimetidine given four times a day (20-40 mg/kg/24 hr )

metoclopramide (0.5 mg/kg/dose) 4 times a day

cisapride, 0.2mg/kg qid

If symptoms do not respond to a 6wk trial of intensive medical therapy, operative treatment may be indicated

TreatmentTreatment

Bougienage of strictures can provide temporary relief of dysphagia

Nissen fundoplication

TreatmentTreatment

TreatmentTreatment

occasionally, stricture formation is so extensive that colonic interposition is required to replace a portion of the esophagus

Thank You!

jgyif

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