Page 163 - Medicine and Surgery

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Chapter 4: Disorders of the oesophagus 159

South America is very similar where infection by Try- oesophageal sphincter. Surgical intervention is indicated
panosoma cruzi causes destruction of the myenteric in those who fail to respond; a 10–12 cm incision is made
plexus. into the anterior wall of the oesophagus without breach-
ing the mucosa (Heller’s cardiomyotomy). Laparoscopic
Pathophysiology techniques are also used. Gastro-oesophageal reflux is a
The neuromuscular damage causes disordered motility complication with both procedures.
along the whole length of the oesophagus. On manom-
etry there is aperistalsis and incomplete relaxation of Diffuse oesophageal spasm
the lower oesophageal sphincter in response to swallow-
ing. The gastrooesophageal sphincter classically remains Definition
Asevere form of abnormal oesophageal mobility.
tightly closed and there is dilation of the oesophagus.
Aetiology/pathophysiology
Clinical features
There is a generalised abnormality of the oesopha-
Patients present with progressive dysphagia, regurgita-
gus with resultant hypermotility leading to painful oe-
tionandnocturnalaspiration.Retrosternalburningpain
sophageal spasms. The resting pressure and relaxation of
occurs in around a quarter of patients. Patients are often
the lower oesophageal sphincter is normal.
underweight.
Clinical features
Complications Painisretrosternalandrangesfrommildtoseverecolicky
Patients may aspirate and develop respiratory symp- spasms that occur spontaneously or on swallowing.
toms. Achalasia may predispose to oesophageal car-
cinoma even after successful treatment (incidence of Investigations
5–10%). Barium swallow may show a corkscrew appearance due
to contracted muscle (nutcracker oesophagus). Manom-
Investigations etry can be used to identify the diseased segment and is
Achest X-ray may reveal a fluid level behind the heart.
required prior to surgery.
Diagnosis is made by barium swallow, which reveals

a markedly dilated ‘megaoesophagus’. There may be Management
superficial mucosal erosions with a very narrow pas- Calcium channel blockers can reduce the amplitude
sage of barium (rat’s tail) into the stomach through of the contractions. Nitrates have also been used with
the contracted lower oesophageal sphincter. some success. Surgical intervention with open or tho-
24-hour pH and manometry studies can differentiate
racoscopic myotomy is considered in refractory cases.
achalasia from other oesophageal motility disorders. The myotomy should extend the entire length of the
Upper gastrointestinal endoscopy is performed to ex-
involved segment of oesophagus and through the lower
clude a tumour. Classically there is a dilated oesoph- oesophageal sphincter. To prevent gastrooesophageal re-
agus containing food debris. The gastrooesophageal flux a fundoplication should also be performed (see
junction may or may not be tight. A normal upper page 158).
gastrointestinal endoscopy does not exclude the diag-
nosis of achalasia. Biopsy reveals inflammation and Mallory-Weiss tear
mucosal ulceration in the oesophagus secondary to
bacterial overgrowth. Definition
Atear in the mucosa normally at or just above the oe-
Management sophageal gastric junction.
Patients require long-term treatment with a proton
pump inhibitor. Treatment is by repeated dilatation of Aetiology/pathophysiology
the lower oesophageal sphincter with a hydrostatic bal- The tear in the mucosa is a result of a sudden increase
loon and/or injection of botulinum toxin into the lower in intra abdominal pressure associated with vomiting,