Treatment of achalasia of the cardia

Treatment of achalasia cardia has several goals:

Elimination of the functional barrier to the passage of food in the form of an unrelaxed lower esophageal sphincter and prevention of the development of complications of the disease.

The most effective are pneumocardiodilation and cardiomyotomy surgery. Drug therapy is of auxiliary importance.

Indications for hospitalization

Treatment of achalasia of the cardia is carried out in a hospital setting.

Urgent hospitalization is necessary

• if it is impossible to take food through the mouth;
• in the development of aspiration pneumonia and the need for intravenous administration of antibiotics or artificial ventilation of the lungs (ALV).

Indications for specialist consultation

Occur when surgical treatment is necessary: achalasia itself - surgeon; complications in the form of an esophageal tumor - oncologist. If parenteral nutrition is necessary, it is advisable to consult a specialist in nutritional therapy.

Non-drug treatment of achalasia cardia

Mode

Limit stress: physical, especially on the abdominal muscles, psychological (sleep at least 8 hours a day).

Diet

Patients with achalasia cardia must follow a certain diet and special recommendations regarding food intake.

Immediately after eating, a horizontal body position should be avoided; during sleep, a strictly horizontal body position is also not recommended, since food can linger in the esophagus for up to several hours, and the upper esophageal sphincter relaxes during sleep, which creates the preconditions for aspiration. Food should be taken slowly, chewing it thoroughly.

Food should not be too cold or too hot, and the diet should exclude foods that may increase dysphagia in specific patients.

It should be taken into account that the volume of food should not be excessive, since overeating leads to a deterioration in the patient's condition. It is recommended to follow a four- or five-time meal regimen.

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Cardiodilation

The most common and effective method of treating achalasia cardia. The essence of the method is the forced expansion of the lower esophageal sphincter with a balloon, into which air or water is pumped under high pressure.

Indications for cardiodilation:

• newly diagnosed achalasia of the cardia types I and II; relapse of the disease after previously performed cardiodilation.

Cardiac dilation for achalasia is not indicated in the following situations.

• Uncorrectable bleeding disorder. Associated esophageal varices or stricture.
• Ineffectiveness of three-time cardiodilation. History of esophageal perforation after cardiodilation.
• The presence of concomitant diseases that significantly increase the risk of surgical treatment (since cardiodilation can lead to perforation of the esophagus, which will require surgical treatment).
• The probability of esophageal perforation during its pneumocardiodilation is about 3%.
• In cases of significant curvature of the esophagus, the technique of endoscopic cardiodilation is proposed.

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Application of botulinum toxin

Other methods of reducing the tone of the lower esophageal sphincter include intramural administration of botulinum toxin or sclerosants (e.g., 1% sodium tetradecyl sulfate, 5% ethanolamine oleate, 5% sodium moruate, 1% ethosysclerol) into the lower esophageal sphincter using an endoscopic needle. Botulinum toxin is administered in a dose of 50-100 U directly into the lower esophageal sphincter. Repeated administration procedures are necessary. The administration of botulinum toxin has limited value: only 30% of patients do not experience dysphagia after endoscopic treatment. Endoscopic methods of treating achalasia are indicated for patients who cannot undergo cardiodilation and cardiomyotomy.

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Drug treatment of achalasia cardia

The most effective medications are calcium channel blockers and nitrates. Indications for their use are as follows:

• Need to relieve symptoms before performing cardiodilation or cardiomyotomy.
• Ineffectiveness or partial effect of other treatment methods.
• The presence of severe concomitant diseases that preclude the possibility of cardiodilation or cardiomyotomy.

Drugs used:

Nitrendipine at a dose of 10-30 mg 30 minutes before meals sublingually. Isosorbide dinitrate at a dose of 5 mg 30 minutes before meals sublingually or at a dose of 10 mg orally.

Surgical treatment of achalasia cardia

Cardiomyotomy

Myotomy of the lower esophageal sphincter region is performed - cardiomyotomy. Indications for its implementation: newly diagnosed achalasia of the cardia of types I and II; relapse of the disease after previously performed cardiodilation.

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Contraindications

• The presence of concomitant diseases that significantly increase the risk of surgical treatment.
• Uncorrectable bleeding disorder.
• Presence of varicose veins of the esophagus.

Cardiomyotomy is usually performed using an open approach, but in recent years, the endoscopic approach to performing cardiomyotomy has become widespread. Both laparoscopic and thoracoscopic techniques are used. It is recommended to combine cardiomyotomy with fundoplication to prevent pathological gastroesophageal reflux.

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Gastrostomy

The possibility of placing a gastrostomy tube for feeding the patient should be considered when non-surgical treatment is ineffective and the risk of a surgical approach is high.

Esophagectomy

Esophagectomy should be considered when other treatments for achalasia cardia have failed or when operable esophageal cancer is present. Esophagectomy followed by esophagoplasty is indicated in the following situations.

Ineffectiveness of adherence to dietary recommendations, drug therapy, cardiodilatation and surgical treatment in the case of an unacceptable quality of life of the patient due to severe manifestations of achalasia of the cardia.

The development of persistent manifestations of gastroesophageal reflux disease or its complications, in the treatment of which drug and surgical methods have proven ineffective, and the patient's quality of life is unacceptably low. The development of esophageal cancer, provided that it is operable

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Treatment of complications of achalasia cardia

If it is impossible to take food through the mouth, the following measures are indicated:

• Intravenous fluids to correct dehydration and electrolyte disturbances that often occur in these patients.
• Intravenous administration of drugs that cannot be administered orally.
• Aspiration of esophageal contents through a nasoesophageal tube to prevent regurgitation and vomiting of swallowed saliva.
• Total parenteral nutrition if radical treatment must be delayed for several days. In case of esophageal perforation due to cardiodilation, the following measures are necessary.
• Urgent consultation with a surgeon (open surgery is usually indicated, although there are reports of successful laparoscopic treatment).
• Aspiration of esophageal contents through a nasoesophageal tube to prevent regurgitation and vomiting of swallowed saliva.
• Intravenous fluids to correct dehydration and electrolyte disturbances that often occur in these patients.
• Parenteral administration of broad-spectrum antibiotics, directed primarily against the microflora of the oral cavity.
• Parenteral administration of narcotic analgesics for severe pain syndrome.

Further management of the patient

Monitoring of patients with achalasia of the cardia is carried out in a specialized hospital.

Events

Questioning the patient: assessment of disease progression and its rate. Frequency: once every 6-12 months.

Physical examination: detection of signs of complications of achalasia - aspiration pneumonia, esophageal cancer. Frequency: once every 6-12 months.

Laboratory examination: complete blood count, complete urine analysis, bloodalbumin levels. Frequency as needed if there is a suspicion of inadequate nutrient intake due to achalasia.

Instrumental examination (FEGDS, radiography): assessment of disease progression and its rate, timely detection of complications of the disease. Frequency: once every 6-12 months or as needed in the presence of characteristic clinical manifestations.

Additionally, it is necessary to specifically identify possible side effects of the medications used if their long-term use is necessary.

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Therapy evaluation criteria

• Recovery - the criteria for the effectiveness of treatment of achalasia of the cardia are the complete disappearance of dysphagia, normalization of the passage of contrast agent through the esophagus into the stomach during X-ray examination.
• Improvement- significant reduction in signs of dysphagia, minor delay in the passage of contrast agent through the esophagus into the stomach during X-ray examination.
• Unchanged - persistence of dysphagia, previous radiographic picture, absence of reflex of opening of the lower esophageal sphincter during intraesophageal manometry.
• Deterioration- increasing dysphagia, the appearance of signs of dehydration, ketonuria, the addition of pulmonary complications (pneumonia).

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Patient education

The patient must be provided with complete information about the upcoming treatment measures.

The patient must be informed that not all patients experience a positive effect from treatment, i.e. a situation may arise where the measures taken do not lead to an improvement in the patient’s condition.

The patient must understand that the disappearance of the manifestations of the disease under the influence of the therapy does not mean a complete cure, so it is necessary to continue to follow the doctor's recommendations.

The patient should be warned against using tablet dosage forms containing substances that can have a damaging effect on the esophageal mucosa:

• acetylsalicylic acid (including small doses necessary for the prevention of vascular accidents);
• nonsteroidal anti-inflammatory drugs (NSAIDs), even enteric-coated ones;
• ascorbic acid;
• iron sulfate;
• potassium chloride;
• alendronate;
• doxycycline;
• quinidine in the form of sustained-release tablets.

If it is impossible to refuse to use the above medications, they should be washed down with a glass of water and taken in a standing position. The patient should be informed about the manifestations of complications of achalasia cardia, so that if they develop, he can seek medical help in time.

Working capacity

Working capacity is not impaired as long as dysphagia is only temporary or occurs with certain foods and can be overcome by appropriate adjustment of the diet or drinking, as long as nutrition is not reduced, the esophagus is not dilated and the esophagitis is not too intense. It is necessary to remember the importance of psychogenic factors in these lesions. If there are signs of neurosis, the conclusion is made taking them into account; this also applies to periodic spasms of the esophagus, which are almost always a neuropathic disorder.

For people with achalasia, work with mental stress and night shifts, etc. is not suitable. Conservative treatment of achalasia cardia should be started with stopping work, during which the patient should rest, get used to the correct way of eating, i.e. in a state of complete rest, in the absence of physical and mental stress, and use sedative and antispasmodic treatment.

If there is more severe dysphagia, constant, for all solid food substances, weight loss, esophageal dilation, more pronounced concomitant esophagitis with congestion or pulmonary complications, it is appropriate to establish disability for the period of treatment, which can be dilatational or surgical. In case of a negative result or impossibility of active treatment, the patient is transferred to disability (complete), regardless of the type of work.

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