Esophageal Cancer

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Posted by bender 04/08/2009 @ 00:11

Tags : esophageal cancer, cancers, diseases, health

News headlines
Alcohol, the 'Asian Flush' and the Risk of Cancer - Voice of America
Researchers found that these drinkers develop a form of esophageal cancer six to ten times more often than those without the deficiency. Esophageal cancer is one of the deadliest cancers. It can be treated when found early, but once it grows the...
Oral bisphosphonate link to esophageal cancer questioned - Modern Medicine
Oral bisphosphonates do not appear to increase risk for esophageal cancer, according to analyses of Danish and US data reported by separate researchers in the April 23 issue of the New England Journal of Medicine. In one study, Bo Abrahamsen, MD,...
Her hope gives her strength - The Sanford Herald
In 2000 Stubits, 40, was diagnosed with esophageal cancer — a disease that attacks the tube that carries food between the patient's mouth and stomach, often causing eating difficulties. It can be fatal. "You go through all of the emotions," Stubits...
Research Examines Reliability Of Clinical And Pathological ... - RedOrbit
Barrett's esophagus itself has no specific symptoms, but this change can increase the risk of esophageal adenocarcinoma (a type of esophageal cancer). Barrett's esophagus can be readily detected during an upper endoscopy but must be confirmed by...
Indiana Cancer Challenge keeping Coach Hep's vision alive - The Herald-Times (subscription)
Marc Bailey, an IU football player from 1971-1973, was diagnosed with esophageal cancer during a routine checkup when he was 52. His doctors only gave him a 15 percent chance to live for six months. Bailey went through 12 weeks of intense treatment and...
Relay helps women 'Look Good ... Feel Better' - Howell County News
Recently, three women in various stages of cancer treatment were present for a Look Good … Feel Better session and shared their reason for attending. Alice Hill of Falling Springs learned this March that she had esophageal and lymph cancer....
2 studies find no link between bisphosphonates, higher cancer risk - SmartBrief
Two US studies found no evidence that bisphosphonates, a class of osteoporosis medicines, increase the risk of esophageal cancer. The results counter FDA data citing cases of esophageal tumors linked to the drugs. An FDA epidemiologist clarified that...
SpectraScience CEO Jim Hitchin Featured in Interview With The Wall ... - PR Newswire (press release)
It is also undergoing clinical trials for an esophageal cancer screening application. During the interview, Mr. Hitchin also reiterated that the company is focusing all resources in sales, adding that it has a competitive advantage from a technology...
Benefit set for Shakopee man with cancer - Shakopee Valley News
Jahn, 43, was diagnosed with stage four esophageal cancer in February. Jahn, who has worked at Anagram in Eden Prairie for 13 years, is unable to work right now as he undergoes chemotherapy. Jahn and his wife, Lisa, have lived in Shakopee since 1992....
Cancer claims life of former CBA standout - Albany Times Union
But he was diagnosed with esophageal cancer 10 months ago. "He was in tremendous shape his whole life," Brian Clemente said. "He ran right up until the day he was diagnosed." Clemente owned the Saugerties-based KTB Associates printing company with his...

Esophageal cancer

Esophageal cancer affecting the lower esophageus. Insets show the tumor in more detail both before and after placement of a stent.

Esophageal cancer is malignancy of the esophagus. There are various subtypes, primarily squamous cell cancer and adenocarcinoma. Squamous cell cancer arises from the cells that line the upper part of the esophagus. Adenocarcinoma arises from glandular cells that are present at the junction of the esophagus and stomach. Esophageal tumors usually lead to dysphagia (difficulty swallowing), pain and other symptoms, and are diagnosed with biopsy. Small and localized tumors are treated surgically with curative intent. Larger tumors tend not to be operable and hence cannot be cured; their growth can still be delayed with chemotherapy, radiotherapy or a combination of the two. In some cases chemo- and radiotherapy can render these larger tumors operable. Prognosis depends on the extent of the disease and other medical problems, but is fairly poor.

Dysphagia (difficulty swallowing) is the first symptom in most patients. Odynophagia (painful swallowing) may be present. Fluids and soft foods are usually tolerated, while hard or bulky substances (such as bread or meat) cause much more difficulty. Substantial weight loss is characteristic as a result of poor nutrition and the active cancer. Pain, often of a burning nature, may be severe and worsened by swallowing, and can be spasmodic in character. An early sign may be an unusually husky or raspy voice.

The presence of the tumor may disrupt normal peristalsis (the organised swallowing reflex), leading to nausea and vomiting, regurgitation of food, coughing and an increased risk of aspiration pneumonia. The tumor surface may be fragile and bleed, causing hematemesis (vomiting up blood). Compression of local structures occurs in advanced disease, leading to such problems as superior vena cava syndrome. Fistulas may develop between the esophagus and the trachea, increasing the pneumonia risk; this symptom is usually heralded by cough, fever or aspiration.

If the disease has spread elsewhere, this may lead to symptoms related to this: liver metastasis could cause jaundice and ascites, lung metastasis could cause shortness of breath, pleural effusions, etc.

Although an occlusive tumor may be suspected on a barium swallow or barium meal, the diagnosis is best made with esophagogastroduodenoscopy (EGD, endoscopy); this involves the passing of a flexible tube down the esophagus and visualising the wall. Biopsies taken of suspicious lesions are then examined histologically for signs of malignancy.

Additional testing is usually performed to estimate the tumor stage. Computed tomography (CT) of the chest, abdomen and pelvis, can evaluate whether the cancer has spread to adjacent tissues or distant organs (especially liver and lymph nodes). The sensitivity of CT scan is limited by its ability to detect masses (e.g. enlarged lymph nodes or involved organs) generally larger than 1 cm. FDG-PET (positron emission tomography) scan is also being used to estimate whether enlarged masses are metabolically active, indicating faster-growing cells that might be expected in cancer. Esophageal endoscopic ultrasound (EUS) can provide staging information regarding the level of tumor invasion, and possible spread to regional lymph nodes.

The location of the tumor is generally measured by the distance from the teeth. The esophagus (25 cm or 10 inches long) is commonly divided into three parts for purposes of determining the location. Adenocarcinomas tend to occur distally and squamous cell carcinomas proximally, but the converse may also be the case.

Most tumors of the esophagus are malignant. A very small proportion (under 10%) is leiomyoma (smooth muscle tumor) or gastrointestinal stromal tumor (GIST). Malignant tumors are generally adenocarcinomas, squamous cell carcinomas, and occasionally small-cell carcinomas. The latter share many properties with small-cell lung cancer, and are relatively sensitive to chemotherapy compared to the other types.

Esophageal cancers are typically carcinomas which arise from the epithelium, or surface lining, of the esophagus. Most esophageal cancers fall into one of two classes: squamous cell carcinomas, which are similar to head and neck cancer in their appearance and association with tobacco and alcohol consumption, and adenocarcinomas, which are often associated with a history of gastroesophageal reflux disease and Barrett's esophagus.

The treatment is determined by the cellular type of cancer (adenocarcinoma or squamous cell carcinoma vs other types), the stage of the disease, the general condition of the patient and other diseases present. On the whole, adequate nutrition needs to be assured, and adequate dental care is vital.

If the patient cannot swallow at all, a stent may be inserted to keep the esophagus patent; stents may also assist in occluding fistulas. A nasogastric tube may be necessary to continue feeding while treatment for the tumor is given, and some patients require a gastrostomy (feeding hole in the skin that gives direct access to the stomach). The latter two are especially important if the patient tends to aspirate food or saliva into the airways, predisposing for aspiration pneumonia.

Surgery is possible if the disease is localised, which is the case in 20-30% of all patients. If the tumor is larger but localised, chemotherapy and/or radiotherapy may occasionally shrink the tumor to the extent that it becomes "operable"; however, this combination of treatments (referred to as neoadjuvant chemoradiation) is still somewhat controversial in most medical circles. Esophagectomy is the removal of a segment of the esophagus; as this shortens the distance between the throat and the stomach, some other segment of the digestive tract (typically the stomach or part of the colon) is placed in the chest cavity and interposed. If the tumor is metastatic, surgical resection is not considered worthwhile, but palliative surgery may offer some benefit.

Laser therapy is the use of high-intensity light to destroy tumor cells; it affects only the treated area. This is typically done if the cancer cannot be removed by surgery. The relief of a blockage can help to reduce dysphagia and pain. Photodynamic therapy (PDT), a type of laser therapy, involves the use of drugs that are absorbed by cancer cells; when exposed to a special light, the drugs become active and destroy the cancer cells.

Chemotherapy depends on the tumor type, but tends to be cisplatin-based (or carboplatin or oxaliplatin) every three weeks with fluorouracil (5-FU) either continuously or every three weeks. In more recent studies, addition of epirubicin (ECF) was better than other comparable regimens in advanced nonresectable cancer. Chemotherapy may be given after surgery (adjuvant, i.e. to reduce risk of recurrence), before surgery (neoadjuvant) or if surgery is not possible; in this case, cisplatin and 5-FU are used. Ongoing trials compare various combinations of chemotherapy; the phase II/III REAL-2 trial - for example - compares four regimens containing epirubicin and either cisplatin or oxaliplatin and either continuously infused fluorouracil or capecitabine.

Radiotherapy is given before, during or after chemotherapy or surgery, and sometimes on its own to control symptoms. In patients with localised disease but contraindications to surgery, "radical radiotherapy" may be used with curative intent.

Patients are followed up frequently after a treatment regimen has been completed. Frequently, other treatments are necessary to improve symptoms and maximize nutrition.

In general, the prognosis of esophageal cancer is quite poor, because so many patients present with advanced disease: The overall five-year survival rate (5YSR) is less than 5%. Individualized prognosis depends largely on stage. Those with cancer restricted entirely to the esophageal mucosa have about an 80% 5YSR, but submucosal involvement brings this down to less than 50%. Extension into the muscularis propria (muscular layer of the esophageus) has meant a 20% 5YSR and extension to the structures adjacent to the esophagus results in a 7% 5YSR. Patients with distant metastases (who are not candidates for curative surgery) have a less than 3% 5YSR. Of all patients undergoing surgery with curative intent, the 5YSR is only about 25%.

Esophageal cancer is a relatively rare form of cancer, but some world areas have a markedly higher incidence than others: China, India and Japan, as well as the United Kingdom, appear to have a higher incidence, as well as the region around the Caspian Sea.

The American Cancer Society estimates that during 2007, approximately 15,560 new esophageal cancer cases will be diagnosed in the United States.

The esophageal cancer incidence and mortality rates for people of African-American descent have been higher than the rate for Caucasians. According to the NCI, incidence of adenocarcinoma of the esophagus, which is associated with Barrett's esophagus, is rising in the United States. This type is more common in Caucasian men over the age of 60.

Multiple reports indicate that esophageal adenocarcinoma incidence has increased during the past 20 years, especially in non-Hispanic white men. Esophageal adenocarcinoma age-adjusted incidence increased in New Mexico from 1973 to 1997. This increase was found in non-Hispanic whites and Hispanics and became predominant in non-Hispanic whites.

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Esophageal dysphagia

Endoscopic image of a non-cancerous peptic stricture, or narrowing of the esophagus, near the junction with the stomach.  This is a complication of chronic gastroesophageal reflux disease, and can be a cause of dysphagia. The stricture is about 3 to 5 mm in diameter. The blood that is visible is from the endoscope bumping into the stricture.

Esophageal dysphagia arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach. Usually due to mechanical causes or motility problems.

Patients usually complain of dysphagia (the feeling of food getting stuck several seconds after swallowing), and will point to the suprasternal notch or behind the sternum as the site of obstruction. If there is dysphagia to both solids and liquids, then it is most likely a motility problem. If there is dysphagia initially to solids but progresses to also involve liquids, then it is most likely a mechanical obstruction. Once a distinction has been made between a motility problem and a mechanical obstruction, it is important to note whether the dysphagia is intermittent or progressive. An intermittent motility dysphagia likely can be diffuse esophageal spasm (DES) or nonspecific esophageal motility disorder (NEMD). Progressive motility dysphagia disorders include scleroderma or achalasia with chronic heartburn, regurgitation, respiratory problems, or weight loss. Intermittent mechanical dysphagia is likely to be an esophageal ring. Progressive mechanical dysphagia is most likely due to peptic stricture or esophageal cancer.

Esophageal stricture, or narrowing of the esophagus, is usually a complication of acid reflux, most commonly due to gastroesophageal reflux (GERD). These patients are usually older and have had GERD for a long time. Esophageal stricture can also be due to other causes, such as acid reflux from Zollinger-Ellison syndrome, trauma from NG tube placement, and chronic acid exposure in patients with poor esophageal motility from scleroderma. Other non-acid related causes of peptic strictures include infectious esophagitis, ingestion of chemical irritant, pill irritation, and radiation. Peptic stricture is a progressive mechanical dysphagia, meaning patients will complain of initial intolerance to solids followed by inability to tolerate liquids. When the diameter of the stricture is less than 12 mm the patient will always have dysphagia, while dysphagia is not seen when the diameter of the stricture is above 30 mm. Symptoms relating to the underlying cause of the stricture usually will also be present.

Esophageal cancer also presents with progressive mechanical dysphagia. Patients usually come with rapidly progressive dysphagia first with solids then with liquids, weight loss (> 10 kg), and anorexia (loss of appetite). Esophageal cancer usually affects the elderly. Esophageal cancers can be either squamous cell carcinoma or adenocarcinoma. Adenocarcinoma is the most prevalent in the US and is associated with patients with chronic GERD who has developed Barrett's esophagus (intestinal metaplasia of esophageal mucosa). Squamous cell carcinoma is more prevalent in Asia and is associated with tobacco smoking and alcohol use.

Esophageal rings and webs, are actual rings and webs of tissue that may occlude the esophageal lumen.

Achalasia is an idiopathic motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation as well as loss of peristalsis in the distal esophagus, which is mostly smooth muscle. Both of these features impair the ability of the esophagus to empty contents into the stomach. Patients usually complain of dysphagia to both solids and liquids. Dysphagia to liquids, in particular, is a characteristic of achalasia. Other symptoms of achalasia include regurgitation, night coughing, chest pain, weight loss, and heartburn. The combination of achalasia, adrenal insufficiency, and alacrima (lack of tear production) in children is known as the triple A (Allgrove) syndrome. In most cases the cause is unknown (idiopathic), but in some regions of the world, achalasia can also be caused by Chagas disease due to infection by Trypanosoma cruzi.

Scleroderma is a disease characterized by atrophy and sclerosis of the gut wall, most commonly of the distal esophagus (~90%). Consequently, the lower esophageal sphincter cannot close and this can lead to severe gastroesophageal reflux disease (GERD). Patients typically present with progressive dysphagia to both solids and liquids secondary to motility problems or peptic stricture from acid reflux.

Spastic motility disorders include diffuse esophageal spasm (DES), nutcracker esophagus, hypertensive lower esophageal sphincter, and nonspecific spastic esophageal motility disorders (NEMD).

Once a patient complains of dysphagia they should have an upper endoscopy. Commonly patients are found to have esophagitis and may have an esophageal stricture. Biopsies are usually done to look for evidence of esophagitis even if the EGD is normal. Usually no further testing is required if the diagnosis is established on EGD. Repeat endoscopy may be needed for follow up.

If achalasia suspected an upper endoscopy is required to exclude a malignancy as a cause of the findings on barium swallow. manometry is performed next to confirm. A normal endoscopy should be followed by manometry, and if manometry is also normal, the diagnosis is functional dysphagia.

The patient is generally sent for a GI, pulmonary, or ENT, depending on the suspected underlying cause. A consultation with a speech therapist may also be needed, as many patients may need dietary modifications.

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Alcohol flush reaction

Alcohol flush reaction (Asian Flush, Asian Glow, Red Cheeks, Oriental Flush, Big Blush) is a condition in which the body cannot break down ingested alcohol completely, due to a missense polymorphism that encodes the enzyme, acetaldehyde dehydrogenase (ALDH2) , normally responsible for breaking down acetaldehyde, a product of the metabolism of alcohol. Flushing, or blushing, is associated with the erythema (reddening caused by dilation of capillaries) of the face, neck, shoulder, and in some cases, the entire body after consumption of alcohol.

Research has shown that a history of facial flushing when drinking is indicative of ALDH2 deficiency, and that a ALDH2-deficient drinker has 6 to 10 times the risk of developing esophageal cancer as a drinker not deficient in the enzyme.

Ordinarily, alcohol dehydrogenase (ADH) is responsible for conversion of primary alcohols to aldehydes; aldehydes are then converted to carboxylic acids by aldehyde dehydrogenase (ALDH). In the case of ethanol, the alcohol found in alcoholic beverages, ethanol is converted first into acetaldehyde and then into acetic acid. Acetaldehyde is the most toxic of these three compounds, and is both a possible carcinogen and a major cause of hangovers; ethanol's toxicity is lower, and acetic acid is relatively harmless.

The result is the accumulation of acetaldehyde. Approximately half of people of Asian descent are considered to be sensitive to alcohol due to this condition. Flushing, after consuming one or two alcoholic beverages, includes a range of symptoms: nausea, headaches, light-headedness, an increased pulse, occasional extreme drowsiness, and occasional skin swelling and itchiness. These unpleasant side effects often prevent further drinking that may lead to further inebriation, but the symptoms can lead to mistaken assumption that the people affected are more easily inebriated than others.

Much anecdotal evidence suggests that ingestions of low doses of heartburn medicine, containing ranitidine or famotidine (such as Zantac or Pepcid AC), may be able to relieve the body of the symptoms if taken an hour before drinking.

It is not known definitively why ranitidine and famotidine may, in some cases, but not all, help reduce the symptoms of the alcohol flush reaction.

One possible theory that may explain the effects of famotidine (and similar classed drugs) on the skin erythema or redness secondary to alcohol consumption is because the drugs are H2-antagonists or H2 antihistamines, which are used to treat peptic/gastric ulcers. In essence, if the "Asian flush" is an allergic reaction to the alcohol, then the mechanism of action of H2-antagonists can explain its effects on curtailing or decreasing the redness. However, H2-antagonists do not actually reduce blood concentrations of histamine, but rather works by reversing the effect of histamine on the H2 receptor, and so this theory is disputed.

Another theory, is that acetaldehyde causes the redness and vasodialation, and because the H2-antagonist class of medicine inhibits the ADH enzyme(the conversion from ethanol to acetaldehyde) both in the GI tract and in the liver, the conversion happens at a much slower pace, reducing the effects acetaldehyde has on the drinker. The idea that acetaldehyde is the cause of the flush is also shown by the clinical use of Antabuse, which blocks the removal of acetaldehyde from the body via ALDH inhibition. The high acetaldehyde concentrations described share similarity to symptoms of the flush(flushing of the skin, accelerated heart rate, shortness of breath, throbbing headache, mental confusion and sight being hazy).

Although many people with this condition view it as a lifetime inconvenience, some people have suggested that they can condition their body to be more tolerant of alcohol with repeated, moderate drinking, perhaps increasing the concentration of ALDH2 to metabolize acetaldehyde. Unfortunately, acetaldehyde is a known carcinogen; recent research suggests that alcohol flush-afflicted individuals consuming alcohol continually may be at a higher risk for alcohol-related diseases, such as liver and esophageal cancers and digestive tract cancer.

Studies in rats have also shown that consumption of carbohydrates (glucose & fructose) significantly increase the metabolism of ethanol through a yet unknown pathway, and without affecting alcohol dehydrogenase activity.

Individuals who experience the alcohol flushing reaction may be less prone to alcoholism. Antabuse, a drug sometimes given as treatment for alcoholism, works by inhibiting acetaldehyde dehydrogenase, causing a five to tenfold increase in the concentration of acetaldehyde in the body. The resulting irritating flushing reaction is intended to discourage alcoholics from drinking.

Persons prone to the condition also have lower blood pressure, perhaps as a result of their much lower levels of drinking alcohol.

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Robert Theobald

Robert Theobald (June 11, 1929 in England-November 27, 1999) was a private consulting economist and futurist author best known for his writings on the economics of abundance and his advocacy of a Basic Income Guarantee. Theobald was a member of the Ad Hoc Committee on the Triple Revolution in 1964, and later listed in the top 10 most influential living futurists in The Encyclopedia of the Future. Theobald died of esophageal cancer at his home in Spokane, Washington, shortly after returning from Australia.

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Tom Dunn

Tom Dunn (May 1, 1929 – July 2, 2006) was an anchor and reporter at several New York television stations.

Dunn was born in Warwick, New York, and was a child actor at radio station WAAT in Newark, New Jersey. He started in television at WCTV in Tallahassee, Florida in 1959 after leaving the army. He served as press secretary to U.S. Representative (and later Senator) Ed Gurney (R-FL), then worked as an anchor and reporter for WTVT in Tampa, Florida from 1962 to 1964 before moving to WCBS-TV where he worked from 1964 to 1968. Mr. Dunn served in that same role for WABC-TV from 1968-1970 and at WOR-TV from 1971-1987. Among his duties at WOR was anchoring the long-running News at Noon. He later worked for WPTV-TV in West Palm Beach until his retirement in the late 1990s.

Dunn died of esophageal cancer in Stuart, Florida on July 2, 2006.

His wife, Anna Dunn reported that Richard Nixon asked Dunn to be his press secretary, but he turned down the position because he feared he might not be able to get back into television news if he took the job. Mr. Dunn was an avid sailor, skier, cooking enthusiast and voracious reader. Mr. Dunn also appeared in several motion pictures, including Turk 182 and Without A Trace.

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Schematic of manometry in achalasia showing aperistaltic contractions, increased intraesophageal pressure and failure of relaxation of the lower esophageal sphincter.

Achalasia, also known as esophageal achalasia, achalasia cardiae, cardiospasm, and esophageal aperistalsis, is an esophageal motility disorder: The smooth muscle layer of the esophagus loses normal peristalsis (muscular ability to move food down the esophagus), and the lower esophageal sphincter (LES) fails to relax properly in response to swallowing.

Achalasia is characterized by difficulty swallowing, regurgitation, and sometimes chest pain. Diagnosis is reached with esophageal manometry and barium swallow X-ray studies. Various treatments are available, although none cure the condition completely. Certain medications or Botox may be used in some cases, but more permanent relief is brought by esophageal dilatation and surgical cleaving of the muscle (Heller myotomy).

The most common form is primary achalasia, which has no known underlying cause. However, a small proportion occurs as a secondary result of other conditions, such as esophageal cancer or Chagas disease (an infectious disease common in South America). Achalasia affects about one person in 100,000 per year.

The main symptoms of achalasia are dysphagia (difficulty in swallowing) and regurgitation of undigested food. Dysphagia tends to become progressively worse over time and to involve both fluids and solids. Some achalasia patients also experience weight loss, coughing when lying in a horizontal position, and chest pain which may be perceived as heartburn. Food and liquid, including saliva, are retained in the esophagus and may be inhaled into the lungs (aspiration), potentially leading to aspiration pneumonia.

Due to the similarity of symptoms, achalasia can be mistaken for more common disorders such as gastroesophageal reflux disease (GERD), hiatus hernia, and even psychosomatic disorders.

Specific tests for achalasia are barium swallow and esophageal manometry. In addition, endoscopy of the esophagus, stomach and duodenum (esophagogastroduodenoscopy or EGD), with or without endoscopic ultrasound, is typically performed to rule out the possibility of cancer. The internal tissue of the esophagus generally appears normal in endoscopy, although a "pop" may be observed as the scope is passed through the non-relaxing lower esophageal sphincter with some difficulty, and food debris may be found above the LES.

The patient swallows a barium solution, with continuous fluoroscopy (X-ray recording) to observe the flow of the fluid through the esophagus. Normal peristaltic movement of the esophagus is not seen. There is acute tapering at the lower esophageal sphincter and narrowing at the gastro-esophageal junction, producing a "bird's beak" or "rat's tail" appearance. The esophagus above the narrowing is often dilated (enlarged) to varying degrees as the esophagus is gradually stretched over time. An air-fluid margin is often seen over the barium column due to the lack of peristalsis. A five-minute timed barium swallow can provide a useful benchmark to measure the effectiveness of treatment.

Because of its sensitivity, manometry (esophageal motility study) is considered the key test for establishing the diagnosis. A thin tube is inserted through the nose, and the patient is instructed to swallow several times. The probe measures muscle contractions in different parts of the esophagus during the act of swallowing. Manometry reveals failure of the LES to relax with swallowing and lack of functional peristalsis in the smooth muscle esophagus.

Biopsy, the removal of a tissue sample during endoscopy, is not typically necessary in achalasia, but if performed shows hypertrophied musculature and absence of certain nerve cells of the myenteric plexus, a network of nerve fibers that controls esophageal peristalsis.

Drugs that reduce LES pressure may be useful, especially as a way to buy time while waiting for surgical treatment. These include calcium channel blockers such as nifedipine, and nitrates such as isosorbide dinitrate and nitroglycerin. However, many patients experience unpleasant side effects such as headache and swollen feet, and these drugs often stop helping after several months.

Botulinum toxin (Botox) may be injected into the lower esophageal sphincter to paralyze the muscles holding it shut. As in the case of cosmetic Botox, the effect is only temporary, and symptoms return relatively quickly in most patients. Botox injections cause scarring in the sphincter which may increase the difficulty of later Heller myotomy. This therapy is only recommended for patients who cannot risk surgery, such as elderly persons in poor health.

In balloon (pneumatic) dilation or dilatation, the muscle fibers are stretched and slightly torn by forceful inflation of a balloon placed inside the lower esophageal sphincter. Gastroenterologists who specialize in achalasia and have performed many of these forceful balloon dilatations achieve better results and fewer perforations. There is always a small risk of a perforation which requires immediate surgical repair. Pneumatic dilatation causes some scarring which may increase the difficulty of Heller myotomy if the surgery is needed later. Gastroesophageal reflux (GERD) occurs after pneumatic dilatation in some patients. Pneumatic dilatation is most effective on the long term in patients over the age of 40; the benefits tend to be shorter-lived in younger patients. It may need to be repeated with larger balloons for maximum effectiveness.

Heller myotomy helps 90% of achalasia patients. It can usually be performed by a keyhole approach, or laparoscopically. The myotomy is a lengthwise cut along the esophagus, starting above the LES and extending down onto the stomach a little way. The esophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner muscosal layer intact. A partial fundoplication or "wrap" is generally added in order to prevent excessive reflux, which can cause serious damage to the esophagus over time. After surgery, patients should keep to a soft diet for several weeks to a month, avoiding foods that can aggravate reflux.

Temporary improvement of achalasia symptoms in some cases has been reported with acupuncture, traditional Chinese herbal medicine, and relaxation techniques.

Both before and after treatment, achalasia patients may need to eat slowly, chew very well, drink plenty of water with meals, and avoid eating near bedtime. Raising the head of the bed or sleeping with a wedge pillow promotes emptying of the esophagus by gravity. After surgery or pneumatic dilatation, proton pump inhibitors can help prevent reflux damage by inhibiting gastric acid secretion; and foods that can aggravate reflux, including ketchup, citrus, chocolate, mint, alcohol, and caffeine, may need to be avoided.

Follow-up monitoring: Even after successful treatment of achalasia, swallowing may still deteriorate over time. The esophagus should be checked every year or two with a timed barium swallow because some may need pneumatic dilatations, a repeat myotomy, or even esophagectomy after many years. In addition, some physicians recommend pH testing and endoscopy to check for reflux damage, which may lead to a premalignant condition known as Barrett's esophagus or a stricture if untreated.

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Source : Wikipedia