AHN UNIT 1
Disorders of mouth and
esophagus
(06) Achalasia
BY
MARWAN KHAN
Lecturer
KMU
IHS
SWAT
Objectives
At the end of this presentation students will be able
to :
✘ Discuss the causes, pathophysiology and
manifestations of Achalasia
✘ Discuss the diagnostic, medical and surgical
management of Achalasia
✘ Apply nursing process with ADPIE Format of care to
client of Achalasia
✘ Develop a teaching plan for a client experiencing
disorder of Achalasia
What is achalasia?
✘ Achalasia is a rare disorder in which your esophagus is
unable to move food and liquids down into your stomach.
Your esophagus is the muscular tube that transports food
from your mouth to your stomach. At the area where your
esophagus meets your stomach is a ring of muscle called
the lower esophageal sphincter (LES). This muscle
relaxes (opens) to allow food to enter your stomach and
contracts (tightens to close) to prevent stomach content
from backing up into your esophagus. If you have
achalasia, the LES doesn’t relax, which prevents food
Cont..
Achalasia is a fairly rare condition. Some people mistake it for
gastroesophageal reflux disease (GERD). However, in achalasia,
the food is coming from the esophagus. In GERD, the material
comes from the stomach.
There's no cure for achalasia. Once the esophagus is damaged, the
muscles cannot work properly again. But symptoms can usually
be managed with endoscopy, minimally invasive therapy or
surgery.
Who gets achalasia?
✘ Achalasia develops in about 1 in every 100,000 people
in the U.S. each year. It is typically diagnosed in adults
between the ages of 25 and 60, but can occur in
children as well (less than 5% of cases are in children
under age 16). No particular race or ethnic group is
more affected than others, and the condition does not
run in families (except possibly in a rare form of the
disorder). Men and women are equally affected.
Pathophysiology
Achalasia involves two primary pathophysiological defects:
Failure of LES Relaxation:Due to the loss of inhibitory neurons in the
esophageal wall, the LES does not properly relax during swallowing,
leading to functional obstruction.
Absence of Esophageal Peristalsis:The normal sequential contractions
that move food down the esophagus are lost, resulting in a flaccid, non-
contracting esophageal body.
Progression:
With time, retained food and fluids dilate the esophagus (megaesophagus),
which can become tortuous and lead to further motility dysfunction.
Clinical Manifestations
• Difficulty swallowing, called dysphagia, which may feel
like food or drink is stuck in the throat.
• Swallowed food or saliva flowing back into the throat.
• Heartburn.
• Belching.
• Chest pain that comes and goes.
• Coughing at night.
• Pneumonia from getting food in the lungs.
• Weight loss.
• Vomiting.
Causes of Achalasia
Achalasia is primarily idiopathic, meaning the exact cause is unknown. However, several
potential etiologies and associations include:
Degeneration of the Myenteric (Auerbach's) Plexus
The most widely accepted theory regarding the pathogenesis of achalasia
involves the degeneration of the myenteric plexus, a network of
neurons situated between the circular and longitudinal layers of the
muscularis propria of the esophagus. This plexus plays a crucial role in
coordinating esophageal peristalsis and relaxation of the lower
esophageal sphincter (LES) during swallowing.
In achalasia:
• There is selective loss of inhibitory ganglion cells, particularly those
that secrete nitric oxide (NO) and vasoactive intestinal peptide
(VIP).
• The resulting imbalance between excitatory and inhibitory signaling leads
to failure of LES relaxation and absent peristalsis.
• This neurodegeneration is thought to be autoimmune in nature,
Cont…
Infectious Causes:
Chagas disease (caused by Trypanosoma cruzi) can lead to secondary
achalasia by destroying enteric neurons.
Genetic and Autoimmune Factors:
Some familial clustering and autoimmune associations have been reported.
Paraneoplastic Syndromes:
Rarely, achalasia can be associated with malignancies, especially of the lung or
stomach (pseudoachalasia).
1. Diagnostic Approach to
Achalasia
a. Clinical Evaluation: Standard):
• Symptoms: Progressive • Confirms diagnosis.
dysphagia to solids and • Diagnostic findings:
liquids, regurgitation, chest • Incomplete LES relaxation
pain, weight loss, and
aspiration. • Absence of peristalsis in the
• History and physical examination esophageal body
guide suspicion. • Elevated LES resting pressure
b. Barium Swallow (Esophagram): d. Upper Endoscopy (EGD):
• First-line imaging test. • Performed to rule out
• Classic findings: mechanical obstruction or
• "Bird’s beak" appearance: malignancy (e.g.,
Narrowing at the LES with pseudoachalasia).
proximal esophageal dilatation. • May show retained food and fluid
in the esophagus.
• Delayed esophageal emptying.
c. Esophageal Manometry (Gold
2. Medical Management of
Achalasia
Medical treatment is generally palliative, used when surgery or
endoscopic therapy is not feasible.
a. Pharmacological Agents:
Used in high-risk surgical patients or temporarily before
definitive treatment.
1. Calcium Channel Blockers (e.g., Nifedipine):
Lower LES pressure by smooth muscle relaxation.
2. Nitrates (e.g., Isosorbide dinitrate):
Promote LES relaxation.
Side effects: Headache, hypotension.
b. Botulinum Toxin Injection (Botox):
Injected endoscopically into the LES.
Inhibits acetylcholine release → temporary LES relaxation.
Short-term relief, often used in elderly or frail patients.
3. Surgical and Endoscopic
Management
a. Pneumatic (Balloon) Dilation:
• Endoscopic procedure where a balloon is inflated at the LES to disrupt
muscle fibers.
• Effective in many patients, especially older adults.
• Risk: Esophageal perforation
b. Laparoscopic Heller Myotomy:
• Gold standard surgical treatment.
• Involves cutting the LES muscle fibers.
• Usually combined with a partial fundoplication to prevent postoperative
reflux.
• Long-term relief in >90% of cases.
c. Peroral Endoscopic Myotomy (POEM):
• Minimally invasive endoscopic version of Heller myotomy.
• No external incisions.
• Comparable efficacy to surgery; risk of gastroesophageal reflux is slightly
Follow-Up and Monitoring
• Patients require monitoring for:
• Symptom recurrence
• Reflux symptoms post-myotomy or POEM
• Rare complications like esophageal cancer in long-standing
untreated achalasia
Apply nursing process with ADPIE
Format of care to client of Achalasia
1. ASSESSMENT
Gather both subjective and objective data:
Subjective Data:
• Difficulty swallowing (dysphagia) for both solids
and liquids
• Regurgitation of undigested food
• Substernal chest pain or discomfort
• Sensation of food "sticking" in the chest
• Unintentional weight loss
• Heartburn or acid taste in mouth
Objective Data:
• Weight loss (noted during physical exam)
• Malnutrition signs (e.g., muscle wasting, dry
skin)
• Decreased breath sounds (if aspiration has
occurred)
• Diagnostic results:
• Barium swallow showing “bird-beak”
appearance
• Manometry showing absent peristalsis and high
LES pressure
2. NURSING DIAGNOSIS
Based on NANDA-I approved terminology, appropriate
nursing diagnoses may include:
• Imbalanced Nutrition: Less Than Body
Requirements related to difficulty swallowing and
regurgitation as evidenced by weight loss and
malnutrition.
• Risk for Aspiration related to impaired esophageal
clearance and regurgitation.
• Acute Pain related to esophageal spasms.
• Ineffective Health Maintenance related to lack of
knowledge about disease process and management.
• Anxiety related to chronic condition and fear of choking
3. PLANNING (Goals and
Outcomes)
Short-Term Goals:
• Client will verbalize understanding of achalasia and its
treatment.
• Client will consume small, frequent meals without
regurgitation.
• Client will maintain a patent airway and show no signs of
aspiration.
Long-Term Goals:
• Client will maintain or gain weight within target range.
• Client will demonstrate improved swallowing and
reduction in dysphagia.
• Client will adhere to medical or surgical treatment plan
4. IMPLEMENTATION (Nursing
Interventions)
Nutritional Support:
• Encourage small, frequent meals that are soft or
semi-liquid.
• Instruct client to chew food thoroughly and eat
slowly.
• Encourage high-calorie, high-protein supplements
if underweight.
• Position client in upright posture during and after
meals (30–60 minutes).
Aspiration Prevention:
Cont…
Pain Management:
• Administer prescribed medications (e.g., nitrates or calcium
channel blockers) before meals to reduce LES pressure.
• Assess and monitor for chest pain and differentiate from
cardiac pain.
Pre/Post-Procedure Care:
• Prepare client for pneumatic dilation, Heller myotomy, or
POEM if planned.
• Provide education and emotional support pre- and post-
operatively.
Health Education:
• Educate about lifestyle changes: upright posture, avoiding
large meals, avoiding alcohol and spicy foods.
• Explain need for regular follow-up, especially for cancer
5. EVALUATION
• Client demonstrates improved nutritional status (stable
or increased weight).
• Client verbalizes relief from dysphagia or chest
discomfort.
• Client shows no signs of aspiration or respiratory
complications.
• Client adheres to recommended dietary and medical
treatment.
• Client participates actively in managing condition and
attends follow-up visits.
Client Teaching Plan for
Achalasia
1. Teaching Objectives
By the end of the teaching session, the client will be able
to:
• Describe what achalasia is and how it affects swallowing.
• Identify common symptoms and potential complications.
• Demonstrate appropriate dietary and lifestyle
modifications.
• Understand prescribed treatment options and the
importance of follow-up care.
• Recognize signs of complications such as aspiration or
malnutrition.
2. Content Outline
A. Disease Understanding
B. Diagnostic Process
C. Treatment Options
D. Nutrition and Diet
E. Lifestyle Modifications
F. Prevention of Complications
3. Teaching Methods
• Verbal explanation and discussion.
• Use of diagrams and pamphlets.
• Demonstration (e.g., correct eating posture).
• Written handouts with dietary guidelines and
follow-up schedule.
4. Evaluation Methods
• Ask the client to explain achalasia in their own
words.
• Use return demonstration (e.g., simulate correct eating
posture).
• Use teach-back method to confirm understanding of
dietary recommendations.
• Evaluate compliance during follow-up (e.g., weight
maintenance, symptom control).
5. Documentation
• Document all education provided, client’s response, and
References
✘ https://www.mayoclinic.org/diseases-conditions/achalasia/symptoms-causes/syc-
20352850
✘ https://my.clevelandclinic.org/health/diseases/17534-achalasia
✘ Katz, P. O., et al. (2013). ACG Clinical Guideline: Diagnosis and Management of Achalasia.
Am J Gastroenterol, 108(8), 1238–1249.
✘ Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M., Kwong, J., & Roberts, D.
(2020).
Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.).
Elsevier.
✘ https://medlineplus.gov/ency/article/000267.htm
