Synonym:

• Achalasia of oesophagus.
• Definition: Failure of the lower oesophageal sphincter to relax resulting in dilatation and hypertrophy of oesophagus without any demonstrable obstructive lesion.

Aetiology:

Theories
• Due to spasm of cardiac sphincter.
• Functional obstruction due to achalasia, i.e. failure of relaxation. The Auerbach’s plexus located between longitudinal and circular muscle is present but defective.
• Congenital abnormality like megaoesophagus.
• Associated with vitamin B deficiency and trypanosomiasis (Chaga’s disease).
Pathology:
• Oesophagus is dilated, often grossly, dilatations being most obvious in distal two-third.
• Considerable muscular hypertrophy.
• Mucous membrane is stretched, thinned and shows features of inflammation and sometimes ulceration.

• Dilatation when traced downwards, narrows in a funnel shaped manner but a short distance above cardiac end, the oesophagus attains normal dimensions. Muscular movements are normal in last inch of oesophagus.

Clinical features:
• Age: Often female above 40.
• Long standing dysphagia with
• Insidious onset.
• Intermittent symptoms.
• More with liquids and less with solids.
• Patient complains of vomiting which is ‘oesophageal pseudo- vomiting’, several hours after a meal.
• Retrosternal or inter scapular discomfort.
• Aspiration pneumonitis may be present.

Treatment

Medical:
Drugs such as probanthine. Laparoscopic Heller’s Cardiomyotomy is a minimally invasive procedure that opens the tight lower oesophageal sphincter (the valve between the oesophagus and the stomach) by performing a myotomy (cutting the thick muscle of the lower part of the oesophagus and the upper part of the stomach) to relieve the dysphagia. Further, a Dor fundoplication (a partial wrapping of the stomach around the oesophagus to make a low-pressure valve) is performed to prevent reflux from the stomach into the oesophagus following the myotomy.