Esophageal Achalasia., El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy

 
This 32 year old man has been suffering from esophageal achalasia for about 10 years, which he has managed by meticulously cutting and chewing all his food. At that time they offered him a surgery, in a public hospital, but he declined it. The incidence of achalasia is approximately 1 per 100,000 people per year. Chagas disease may cause a similar disorder due to Trypanosoma Cruzi.

Video Endoscopic Sequence 1 of 10.

Esophageal Achalasia.

 This 32 year old man has been suffering from esophageal
 achalasia  for about 10 years, which he has managed
 by meticulously cutting and chewing all his food. At that
 time they offered him a surgery, in a public hospital, but he
 declined it.

 At endoscopy, copious amounts of food and liquid were
 seen in the obviously dilated esophagus.

 The incidence of achalasia is approximately 1 per 100,000
 people per year. Chagas disease may cause a similar
 disorder due to Trypanosoma Cruzi.            Medline.   

The exact cause of achalasia is unknown.

                                                     Medline.

 The diagnosis of achalasia should be suspected in anyone
 complaining of dysphagia for solids and liquids with
 regurgitation of food and saliva. The clinical suspicion
 should be confirmed by a barium esophagram showing
 smooth tapering of the lower esophagus leading to the closed
 lower esophageal sphincter (LES), resembling a "bird's
 beak." Esophageal manometry establishes the diagnosis
 showing esophageal aperistalsis and insufficient LES
 relaxation. All patients should undergo upper endoscopy to
 exclude pseudoachalasia arising from a tumor at the
 gastroesophageal junction.

 For further endoscopic information, download the video clip
 by clicking on the endoscopic image. Wait to be
 downloaded complete then Press Alt and Enter for full
 screen ( Windows Media), Real Player: Ctrl and 3.
 All endoscopic images shown in this Atlas contain
 video clips. We recommend seeing the video clips in full
 screen mode.
 
Achalasia. Detail of a barium swallow study demonstrating the classic bird's beak deformity of the distal esophagus showing a dilated esophagus. Achalasia is an esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter and by the absence of esophageal peristalsis. Progressive dysphagia and regurgitation can compromise oral intake and lead to malnutrition and weight loss. Treatment of moderate to severe cases of achalasia involves either balloon dilation or myotomy.

Video Endoscopic Sequence 2 of 10.

 Achalasia. Detail of a barium swallow study demonstrating
 the classic bird's beak deformity of the distal esophagus
 showing a dilated esophagus.

 Achalasia is an esophageal motor disorder characterized by
 incomplete relaxation of the lower esophageal sphincter and
 by the absence of esophageal peristalsis. Progressive
 dysphagia and regurgitation can compromise oral intake and
 lead to malnutrition and weight loss. Treatment of moderate
 to severe cases of achalasia involves either balloon dilation
 or myotomy.              
                                          Medline.
Barium Swallow. Barium sulfate is a metallic compound that shows up on x-ray and is used to help see abnormalities in the esophagus and stomach When taking the test, you drink a preparation containing this solution. The x-rays track its path through your digestive system.

Video Endoscopic Sequence 3 of 10.

 Barium Swallow.

 Barium sulfate is a metallic compound that shows up on x-ray
 and is used to help see abnormalities in the esophagus and
 stomach.
 When taking the test, you drink a preparation containing this
 solution. The x-rays track its path through your digestive
 system.

 Download the video clip by clicking on the Rx image.
Upper GI series. These problems can be detected with a barium swallow: 1.Narrowing or irritation of the esophagus (the muscular tube between the back of the throat and the stomach) 2. Disorders of swallowing 3. Hiatal hernia (an internal defect that causes the stomach to slide partially into the chest) 4. Abnormally enlarged veins in the esophagus that cause bleeding 5. Ulcers 6. Tumors 7. Polyps (growths that are usually not cancerous, but could be precancerous).

Video Endoscopic Sequence 4 of 10.

Upper GI series.

These problems can be detected with a barium swallow:

1.Narrowing or irritation of the esophagus (the muscular tube between the back of the throat and the stomach)
2. Disorders of swallowing
3. Hiatal hernia (an internal defect that causes the stomach to slide partially into the chest)
4. Abnormally enlarged veins in the esophagus that cause bleeding
5. Ulcers
6. Tumors
7. Polyps (growths that are usually not cancerous, but could be precancerous).

 Download the video clip by clicking on the Rx image.
 
 
Barium swallow showing the entire length of the esophagus with extreme narrowing of the esophago-gastric junction;There is dilatation, tortuosity, S-shaped bend in the lower oesophagus (sigmoid esophagus). There is a smooth narrowing at the lower end of the esophagus referred to as bird-beak appearance. The above appearance is very typical of achalasia of the cardia or cardiospasm.

Video Endoscopic Sequence 5 of 10.

 Barium swallow showing the entire length of the
 esophagus with extreme narrowing of the
 esophago-gastric junction;There is dilatation, tortuosity,
 S-shaped bend in the lower oesophagus (sigmoid
 esophagus). There is a smooth narrowing at the lower end
 of the esophagus referred to as "bird-beak" appearance.
 The above appearance is very typical of achalasia of the
 cardia or cardiospasm.

The bird-beak appearance.

"The bird-beak" appearance.

Barium swallow The esophagus appears dilated, and contrast material passes slowly into the stomach as the LES opens intermittently. The distal esophagus is narrowed and has been described as resembling a bird's beak. The test shows esophageal dilatation.

Video Endoscopic Sequence 6 of 10.

 

 Barium Swallow

    • The esophagus appears dilated, and contrast material passes slowly into the stomach as the LES opens intermittently. The distal esophagus is narrowed and has been described as resembling a bird's beak.
    • The test shows esophageal dilatation.

       Download the video clip by clicking on the Rx
       image.
       

Pneumatic balloon dilation in achalasia. Our patient underwent a dilatation with special ballon used for achalasia. Mechanical therapy for achalasia consists of esophageal dilation, the object of which is to disrupt muscle fibers of the LES, effecting a decrease in LES pressure. Dilation is most commonly performed by using pneumatic balloons. The therapy is successful in decreasing LES pressure in 60-80% of patients; however, this change does not always translate into the relief or improvement of symptoms. Approximately one half of patients experience recurrent symptoms within 5 years. In most of these patients, the disease responds well to repeated dilation therapy.

Video Endoscopic Sequence 7 of 10.

Pneumatic balloon dilation in achalasia.

 Our patient underwent a dilatation with special ballon used
 for achalasia. We do not used fluoroscopic control

                                          Medline.

 Mechanical therapy for achalasia consists of esophageal
 dilation, the object of which is to disrupt muscle fibers of the
 LES, effecting a decrease in LES pressure. Dilation is most
 commonly performed by using pneumatic balloons. The
 therapy is successful in decreasing LES pressure in 60-80% of
 patients; however, this change does not always translate into
 the relief or improvement of symptoms. Approximately one
 half of patients experience recurrent symptoms within 5
 years. In most of these patients, the disease responds well to
 repeated dilation therapy.

Pneumatic dilatation under endoscopic guidance. Pneumatic balloon dilation is considered by many to be the treatment of choice for achalasia of the esophagus. Dilation procedures are done as an outpatient procedure using only mild sedation with fentanyl and midazolam. Sedation is kept to true conscious sedation to assist the operator in evaluating severity of dilation induced chest pain.

Video Endoscopic Sequence 8 of 10.

Pneumatic dilatation under endoscopic guidance.

Pneumatic balloon dilation is considered by many to be the treatment of choice for achalasia of the esophagus. Dilation procedures are done as an outpatient procedure using only mild sedation with fentanyl and midazolam. Sedation is kept to true conscious sedation to assist the operator in evaluating severity of dilation induced chest pain.

 Medline: Long-term follow-up after pneumatic dilation for
 achalasia cardia: factors associated with treatment failure
 and recurrence.
After the esophagus being dilated, we performed a retroflexed maneuver in the esophagus seen the endoscope and the catheter of the balloon. Pneumatic dilatation is considered to be the first line therapy for achalasia, but long-term outcome studies are scarce and limited by their retrospective design.

Video Endoscopic Sequence 9 of 10.

 After the esophagus being dilated, we performed a
 retroflexed maneuver in the esophagus seen the endoscope
 and the catheter of the balloon.

 Pneumatic dilatation is considered to be the first line therapy for
 achalasia, but long-term outcome studies are scarce and limited
 by their retrospective design.

 Medline: Pneumatic balloon dilatation in achalasia: a
 prospective comparison of safety and efficacy with different
 balloon diameters.
The final status of the dilatation. We have performed 24 pneumatic dilations for achalasia in the past 3 years and have had no complication using this protocol. One of the patient of 21 year-old female has Down Syndrome Most prospective studies have shown the effectiveness of pneumatic dilation to be between 60% and 80% and comparable to myotomy.

Video Endoscopic Sequence 10 of 10.

Final status of the dilatation.

 We have performed 24 pneumatic dilations for achalasia in
 the past 3 years and have had no complication using this
 protocol.
 One of the patient of 21 year-old female has Down
 Syndrome Most prospective studies have shown the
 effectiveness of pneumatic dilation to be between 60% and
 80% and comparable to myotomy.

 
Esophageal Achalasia and Bronchoaspiration In this image and the video clip show a bronchoscopy, performed with a regular GI video endoscope in which is observed, material that came from the esophagus that has a achalasia. This 78 year-old female 20 years previously underwent a surgery due to Esophageal Achalasia, (Esophagomyotomy of the lower esophageal sphincter (LES) ). Heller esophagomyotomy, since one month she has vomiting and weight loss. The upper endoscopy shows a typical picture of esophageal achalasia which was dilated with the same balloon that has been showed in this chapter. Esophageal dysfunction progresses through accumulation of ingested material in the superior portion of the esophagus, facilitating the aspiration of this material. This condition is more common in individuals in whom the cough reflex has been lost or suppressed due to neuromuscular disturbances, or due to the use of sedatives or other drugs. In such cases, aspiration pneumonia becomes established.

 Esophageal Achalasia and Bronchoaspiration

 Tracheobronchitis

 In this image and the video clip show a bronchoscopy,
 performed with a regular GI video endoscope in which is
 observed, material that came from the esophagus that has a
 achalasia.

 This 78 year-old female 20 years previously underwent a
 surgery due to Esophageal Achalasia, (Esophagomyotomy
 of the lower esophageal sphincter (LES) ). Heller
 esophagomyotomy, since one month she has vomiting and
 weight loss.

 The upper endoscopy shows a typical picture of esophageal
 achalasia which was dilated with the same balloon that has
 been showed in this chapter. 

 Esophageal dysfunction progresses through accumulation of
 ingested material in the superior portion of the esophagus,
 facilitating the aspiration of this material. This condition is
 more common in individuals in whom the cough reflex has
 been lost or suppressed due to neuromuscular disturbances,
 or due to the use of sedatives or other drugs. In such cases,
 aspiration pneumonia becomes established.

 Pub Med: Surgery for achalasia: long-term results in
 operated achalasic patients.

Esophagus - Pneumatic Dilation for Achalasia.This 33 year old female, 8 years previously underwent an open surgery by chest approach (Heller myotomy) due to esophageal achalasia, since 2 months complained of progressive dysphagia. Endoscopy displays images compatibles of relapsing of the achalasia.

Video Endoscopic Sequence 1 of 17.

Esophagus - Pneumatic Dilation for Achalasia

 This 33 year old female, 8 years previously underwent an
 open surgery by chest approach (Heller myotomy) due to
 esophageal achalasia, since 2 months complained of
 progressive dysphagia. Endoscopy displays images
 compatibles of relapsing of the achalasia.
After removing the food and liquid from the esophagus, the characteristic “pop” is felt as the endoscope is passed through the tight lower esophageal sphincter into the stomach.

Video Endoscopic Sequence 2 of 17.

 After removing the food and liquid from the esophagus, the
 characteristic “pop” is felt as the endoscope is passed
 through the tight lower esophageal sphincter into the
 stomach.

 
AkalasiaRelapsing3

Video Endoscopic Sequence 3 of 17.

In the image as well as the video clip shows a guide wire is placed through the endoscope.

 
Simple endoscopy is performed and the guidewire is placed in the antrum on the greater curve and the distance from the mouthpiece to the z-line recorded.

Video Endoscopic Sequence 4 of 17.

 Simple endoscopy is performed and the guidewire is placed
 in the antrum on the greater curve and the distance from
 the mouthpiece to the z-line recorded.

A Wilson Cook balloon for achalasia with a 30 mm diameter was advanced over the guide wire with the middle of the balloon traversing the GE junction. The goal of therapy for achalasia is to relieve symptoms by eliminating the outflow resistance caused by the hypertensive and nonrelaxing LES. Once the obstruction is relieved, the food bolus can travel through the aperistaltic body of the esophagus by gravity.

Video Endoscopic Sequence 5 of 17.

 A Wilson Cook balloon for achalasia with a 30 mm
 diameter was advanced over the guide wire with the middle
 of the balloon traversing the GE junction.

 The goal of therapy for achalasia is to relieve symptoms by
 eliminating the outflow resistance caused by the
 hypertensive and nonrelaxing LES. Once the obstruction is
 relieved, the food bolus can travel through the aperistaltic
 body of the esophagus by gravity.

 
The rationale for dilation is to produce a controlled tear of the lower esophageal sphincter, which will result in relief of distal esophageal obstruction. This is the most effective non-surgical treatment of achalasia.

Video Endoscopic Sequence 6 of 17.

 The rationale for dilation is to produce a controlled tear of
 the lower esophageal sphincter, which will result in relief of
 distal esophageal obstruction. This is the most effective
 non-surgical treatment of achalasia.

 
As dilation begins, the dilators tend to move into the stomach, and an upward tension should be maintained on the dilator to prevent this movement. The dilator is expanded until the waist is obliterated and maintained in this position for at least 20 seconds; we use 1 to 3 minutes in our unit. Repeat dilation in the same session is used in our unit at least 3, dilation are done. The subsequent balloon inflation will require same balloon pressure to achieve waist obliteration. The use of routine endoscopy or routine barium studies after dilation is not used in our unit. Observation takes place for 4 hours.

Video Endoscopic Sequence 7 of 17.

 As dilation begins, the dilators tend to move into the
 stomach, and an upward tension should be maintained on
 the dilator to prevent this movement. The dilator is
 expanded until the waist is obliterated and maintained in
 this position for at least 20 seconds; we use 1 to 3 minutes
 in our unit. Repeat dilation in the same session is used in
 our unit at least 3, dilation are done. The subsequent
 balloon inflation will require same balloon pressure to
 achieve waist obliteration. The use of routine endoscopy or
 routine barium studies after dilation is not used in our unit.
 Observation takes place for 4 hours

 
Sir Thomas Willis described achalasia in 1672. In 1881, von Mikulicz described the disease as a cardiospasm to indicate that the symptoms were due to a functional problem rather than a mechanical one. In 1929, Hurt and Rake realized that the disease was caused by a failure of the lower esophageal sphincter (LES) to relax. They coined the term achalasia, meaning failure to relax.

Video Endoscopic Sequence 8 of 17.

 Sir Thomas Willis described achalasia in 1672. In 1881, von
 Mikulicz described the disease as a cardiospasm to indicate
 that the symptoms were due to a functional problem rather
 than a mechanical one. In 1929, Hurt and Rake realized
 that the disease was caused by a failure of the lower
 esophageal sphincter (LES) to relax. They coined the term
 achalasia, meaning failure to relax.

 
The gastroesophageal juntion is barely dilated at the first attempt to be dilated.

Video Endoscopic Sequence 9 of 17.

The gastroesophageal juntion is barely dilated at the first attempt to be dilated.

 
The middle of the balloon is generally held about 1 cm above the GE junction as traction of the balloon upon inflation moves the balloon distally into the stomach. Once the balloon is in place, the catheter is held firmly against the bite block to prevent migration of the balloon.

Video Endoscopic Sequence 10 of 17.

 The middle of the balloon is generally held about 1 cm
 above the GE junction as traction of the balloon upon
 inflation moves the balloon distally into the stomach. Once
 the balloon is in place, the catheter is held firmly against
 the bite block to prevent migration of the balloon.

 
There is no consensus on the duration of inflation, we repeated several times until the dilation is performed, bleeding in small quantity is normal.

Video Endoscopic Sequence 11 of 17.

 There is no consensus on the duration of inflation, we
 repeated several times until the dilation is performed,
 bleeding in small quantity is normal.

 
After dilation, the balloon is removed and examined for blood, indicating a tear of the LES and adequate dilation.

Video Endoscopic Sequence 12 of 17.

 After dilation, the balloon is removed and examined for
 blood, indicating a tear of the LES and adequate dilation.

 
Continuing the procedure.

Video Endoscopic Sequence 13 of 17.

Continuing the procedure.
AkalasiaRelapsing14

Video Endoscopic Sequence 14 of 17.

 The balloon emerges from the gastroesophageal junction
 which already dilated.

 
The Balloon is observed from the stomach in retroflexed maneuver, below the Savary guide wire is seen.

Video Endoscopic Sequence 15 of 17.

The Balloon is observed from the stomach in retroflexed maneuver, below the Savary guide wire is seen.
AkalasiaRelapsing16

Video Endoscopic Sequence 16 of 17.

More images and video clips.
AkalasiaRelapsing17

Video Endoscopic Sequence 17 of 17.

Final Status of the Dilation.
A 75 year-old female, who 3 months having had weight loss and persiting vomiting. A forceful maneuvering of the endoscope had to be done, in order to overcome the sphincter. The incidence of achalasia is approximately 1 per 100,000 people per year. Chagas disease may cause a similar disorder due to Trypanosoma Cruzi. The exact cause of achalasia is unknown.

Video Endoscopic Sequence 1 of 16.

Esophageal Achalasia,

 A 75 year-old female, who 3 months ago had started with
 weight loss and persiting vomiting.
 A forceful maneuvering of the endoscope had to be done, in
 order to overcome the sphincter.
 The incidence of achalasia is approximately 1 per 100,000
 people per year. Chagas disease may cause a similar
 disorder due to Trypanosoma Cruzi.
 The exact cause of achalasia is unknown.
The esophagus is found to be dilated with rest of food. Achalasia is a rare disease of the muscle of the esophagus which is usually diagnosed in young adults. The term achalasia means "failure to relax" and refers to one of the abnormalities of the esophagus seen in the disease, specifically. The inability of the muscle at the lower end of the esophagus (the lower esophageal sphincter) to open and let food pass into the stomach. In addition, the muscle of the lower half of the esophagus does not contract normally to propel food down the esophagus and into the stomach. Both of these abnormalities result in food sticking in the esophagus after it is swallowed.

Video Endoscopic Sequence 2 of 16.

 The esophagus is found to be dilated with rest of food.
 Achalasia is a rare disease of the muscle of the esophagus
 which is usually diagnosed in young adults.
 The term achalasia means "failure to relax" and refers to
 one of the abnormalities of the esophagus seen in the
 disease, specifically. the inability of the muscle at the
 lower end of the esophagus (the lower esophageal
 sphincter) to open and let food pass into the stomach. In
 addition, the muscle of the lower half of the esophagus
 does not contract normally to propel food down the
 esophagus and into the stomach. Both of these
 abnormalities result in food sticking in the esophagus after
 it is swallowed.
Retroflexed view of the fundus shows a cardias so tight, the retroflex maneuver can not be performed into the esophagus.

Video Endoscopic Sequence 3 of 16.

 Retroflexed view of the fundus shows a cardias so
 tight, the retroflex maneuver can not be performed
 into the esophagus.
 
 

 
Esofagogram. X-ray finding in a patient with achalasia.

Video Endoscopic Sequence 4 of 16.

Esofagogram.

        X-ray finding in a patient with achalasia.
                
Pneumatic dilation in achalasia under direct visualization. The image and the video display a guide wire placed first To introduce the balloon. A nonsurgical treatment of esophageal achalasia, where the lower esophageal and cardial sphincter is disrupted by overdistension of the circular muscular fibres. The balloon is positioned over a guide wire and positioned through an endoscope under direct vision.