Video Endoscopic Sequence 1 of 31.

Esophagus - Pneumatic Dilation for Achalasia

The GE junction was tight suggestive of motor dysphagia.

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.

For more endoscopic details, download the video clip by clicking on the endoscopic image. Wait to be downloaded complete then Press Alt and Enter for full screen.

All endoscopic images shown in this Atlas contain video clips. We recommend seeing the video clips in full screen mode.

Video Endoscopic Sequence 2 of 31.

Esophagus - Pneumatic Dilation for 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.
Endoscopic diagnostic criteria.

Early:
− Endoscopy may show no abnormalities
− Increased, “springy” resistance to instrument passage
− Failure of the cardia to open during prolonge observation
− Persistent rosette appearance
− Retroflexed view: cardia tightly closed around the
  endoscope

Late:
 −Food residues and fluid in the esophagus
− Esophagus dilated, lax, elongated, tortuous
− Uncoordinated, nonpropulsive, or absent contractions
− Diverticulumlike pouch above the LES
− Increased resistance to cardial intubation
− Mucosal changes due to food retention: padlike
  thickening of the mucosa, erythema, petechiae,
  grayish−yellow deposits, rarely erosions, very rarely
  ulcerations.

Video Endoscopic Sequence 3 of 31.
 

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

Video Endoscopic Sequence 4 of 31.

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 6 of 31.

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

Video Endoscopic Sequence  7 of 31.

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 8 of 31.

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  9 of 31.

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

Video Endoscopic Sequence 10 of 31.

Pneumatic Dilation for Esophageal Achalasia

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  11 of 31.

Endoscopy of Pneumatic Dilation for Esophageal Achalasia

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  12 of 31.

Endoscopy of Pneumatic Dilation for Esophageal Achalasia

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

Video Endoscopic Sequence 13 of 31.

Continuing the procedure.

Video Endoscopic Sequence  14 of 31.

The balloon emerges from the gastroesophageal junction which already dilated.

Video Endoscopic Sequence 15 of 31.

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

Video Endoscopic Sequence 16 of 31.

More images and video clips.

Video Endoscopic Sequence 17 of 31.

Final Status of the Dilation.

Video Endoscopic Sequence 18 of 31.

A follow up endoscopy was performed one year after the dilation.

Retention of liquid in the form of foam is observed, the gastroesophageal junction is permeable and ulcerated, is evident that the motility of the esophagus is lack or abnormal.

Video Endoscopic Sequence 19 of 31.

Lower Third of the Esophagus.

Video Endoscopic Sequence 20 of 21.

The esophagus is so enlarged.

Video Endoscopic Sequence 21 of 31.

Lower Third of the Esophagus, there are multiple ulcerations and a small pseudodiverticula. Incompetent lower esophageal sphincter is evident.

Video Endoscopic Sequence 22 of 31.

More images and video clips of the lower third of the esophagus.

Possibly this patient will need to take by life PPI.

Video Endoscopic Sequence 23 of 31.

Achalasia and Clubbing of the Fingers.

Hippocrates first described digital clubbing in patients with
empyema.

Six months after dilatation of the esophagus patient
initiates with clubbing of the fingers, cardiopulmonary
diseases were ruled out with multiple medical test.

Clubbing can be idiopathic or secondary to many underlying pathologies in various organ systems.

Gastrointestinal disease related with clubbing.

Ulcerative colitis.

Crohn disease.

Primary biliary cirrhosis, cirrhosis of the liver

Leiomyoma of the esophagus achalasia

Peptic ulceration of the esophagus

Colonic or esophageal carcinoma.

Video Endoscopic Sequence 24 of 31.

Digital clubbing has been associated with various underlying pulmonary, cardiovascular, neoplastic, infectious, hepatobiliary, mediastinal, endocrine, and gastrointestinal diseases.

Finger clubbing also may occur, without evident underlying disease, as an idiopathic form or as a Mendelian dominant trait.

Clubbing is aclinically descriptive term, referring to the bulbous uniform swelling of the soft tissue of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed.

Video Endoscopic Sequence 25 of 31.

Computed Tomography.

CT scanning with oral contrast enhancement may demonstrate the gross structural esophageal abnormalities associated with achalasia, especially dilatation, which is seen in advanced stages.

However, CT findings are nonspecific, and the diagnosis of achalasia cannot be made using CT alone.

CT scan may be indicated in the workup of patients with suspected pseudoachalasia.

Video Endoscopic Sequence 26 of 31.

CT findings are nonspecific and insensitive in the early stages of achalasia. CT findings should always be confirmed by means of barium swallow study with fluoroscopy, upper gastrointestinal endoscopy, and esophageal manometry.

Video Endoscopic Sequence 27 of 31.

Video Endoscopic Sequence 28 of 31.

CT scan of the chest demonstrates a markedly dilated esophagus, including its upper region to the gastroesophageal junction. There is a air fluid level, without focal or difuse thickening of the esophageal walls.

Video Endoscopic Sequence 29 of 31.

Video Endoscopic Sequence 30 of 31.

Video Endoscopic Sequence 31 of 31.