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==Medical Therapy==
==Medical Therapy==


*Medication:
===Botulinum Toxin===
**Intra-[[sphincter]]ic injection of [[botulinum toxin]] (or botox), to paralyze the lower esophageal sphincter and prevent [[spasm]]s.  As in the case of botox injected for cosmetic reasons, the effect is only temporary, and symptoms return quickly in most patients. Botox injections cause scarring in the sphincter which may increase the difficulty of later [[Heller myotomy]].  This therapy is only recommended for elderly patients who cannot risk surgery.
Intra-[[sphincter]]ic injection of [[botulinum toxin]] (or botox), to paralyze the lower esophageal sphincter and prevent [[spasm]]s.  As in the case of botox injected for cosmetic reasons, the effect is only temporary, and symptoms return quickly in most patients. Botox injections cause scarring in the sphincter which may increase the difficulty of later [[Heller myotomy]].


::* BoTox acts as a zinc-dependant protease and cleaves a protein called SNAP-25.  This results in a block of acetylcholine release from the presynaptic nerve terminal. As it is the excitatory neurons that release acetylcholine, a decrease in LES tone is observed.
'''Indications'''
::*:* It has also been shown that BoTox interferes with cholinergic signaling in the myenteric nervous system that supplies smooth muscle, and hence also decreases smooth muscle contractility.
* For patients who cannot risk surgery
::* Pasricha et.al. showed that 90% of patients experienced immediate relief, however only 65% have relief at 6 months, and only 42% are symptom free at one year.
* As an adjunct to myotomy to treat residual LES spasms
::*:* Relief was associated with a reduction in LES pressure by 40%, an increase in esophageal diameter by 17%, and a reduction in esophageal retention of 33%.
'''Mechanism of Action'''
::* BoTox is very well tolerated, and only ~ 5% develop symptomatic gastroesphageal reflux disease (GERD).
* BoTox acts as a zinc-dependant protease and cleaves a protein called SNAP-25.  This results in a block of acetylcholine release from the presynaptic nerve terminal. As it is the excitatory neurons that release acetylcholine, a decrease in LES tone is observed.
::* The technique is currently being refined with even better results when injection is guided by endoscopic ultrasound.
* It has also been shown that BoTox interferes with cholinergic signaling in the myenteric nervous system that supplies smooth muscle, and hence also decreases smooth muscle contractility.
::* Some surgeons believe that BoTox can increase the difficulty of future surgery, and therefore recommend it only for patients who are not candidates for dilation or surgery.
* Relief was associated with a reduction in LES pressure by 40%, an increase in esophageal diameter by 17%, and a reduction in esophageal retention of 33%.
'''Adverse Effects'''
* BoTox is very well tolerated, and only ~ 5% develop symptomatic gastroesophageal reflux disease (GERD).
* 16-25% rate of developing chest pain
* [[Mediastinitis]] (rare)
* Allergic reaction to egg protein (rare)
* Higher rate of subsequent surgical complications
* 50% relapse rate
* Requirement for repeat injections (Pasricha et.al. showed that 90% of patients experienced immediate relief, however only 65% have relief at 6 months, and only 42% are symptom free at one year)<ref name="pmid12556788">{{cite journal| author=Zhao X, Pasricha PJ| title=Botulinum toxin for spastic GI disorders: a systematic review. | journal=Gastrointest Endosc | year= 2003 | volume= 57 | issue= 2 | pages= 219-35 | pmid=12556788 | doi=10.1067/mge.2003.98 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12556788  }} </ref><ref name="pmid23877351">{{cite journal| author=Vaezi MF, Pandolfino JE, Vela MF| title=ACG clinical guideline: diagnosis and management of achalasia. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 8 | pages= 1238-49; quiz 1250 | pmid=23877351 | doi=10.1038/ajg.2013.196 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23877351  }} </ref><ref name="pmid23871090">{{cite journal| author=Boeckxstaens GE, Zaninotto G, Richter JE| title=Achalasia. | journal=Lancet | year= 2014 | volume= 383 | issue= 9911 | pages= 83-93 | pmid=23871090 | doi=10.1016/S0140-6736(13)60651-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23871090  }} </ref>


**Drugs that reduce LES pressure may be useful, especially as a way to buy time while waiting for surgical treatment.  These include [[calcium channel blockers]] such as [[nifedipine]], and [[nitrates]] such as [[isosorbide dinitrate]] and [[nitroglycerin]].  Unfortunately, many patients experience unpleasant side effects such as [[headache]] and swollen feet, and these drugs often stop helping after several months.
===Oral Pharmacotherapy===
Drugs that reduce LES pressure may be useful, especially as a way to buy time while waiting for surgical treatment.  [[Calcium channel blockers]] such as [[nifedipine]], and long acting [[nitrates]] such as [[isosorbide dinitrate]] and [[nitroglycerin]] are the two most commonly used groups of medications.


:* Nitrates,
'''Indications'''
:* Aminophylline,
*Drugs are the least effective mode of treatment. They are used temporarily before the more effective mode of treatment such as pneumatic dilation and [[myotomy]] can be used and in high risk patients.
:* Terbutaline
 
:* Ca++ channel blockers
'''Mechanism of action'''
:*:* Decreases LES tone
*They cause [[smooth muscle]] relaxation which leads to reduction in [[lower esophageal sphincter]] pressure and helps in esophageal emptying.
:*:* Usually only provide minimal relief.
 
:*:* As the pills themselves can get stuck in the esophagus, this can complicate the disease.
'''Adverse Effects'''
* [[Headache]]
* [[Hypotension]]
* [[Pedal Edema]]
* Usually only provide minimal relief.
* As the pills themselves can get stuck in the esophagus, this can complicate the disease.
 
Other uncommon drugs which can be used in achalasia management:
[[Sildenafil]],
Theophyllin,
[[Atropine]],
[[Dicyclomine]],
Cimetropium Bromide,
[[Terbutaline]]<ref name="pmid23877351">{{cite journal| author=Vaezi MF, Pandolfino JE, Vela MF| title=ACG clinical guideline: diagnosis and management of achalasia. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 8 | pages= 1238-49; quiz 1250 | pmid=23877351 | doi=10.1038/ajg.2013.196 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23877351  }} </ref><ref name="pmid23871090">{{cite journal| author=Boeckxstaens GE, Zaninotto G, Richter JE| title=Achalasia. | journal=Lancet | year= 2014 | volume= 383 | issue= 9911 | pages= 83-93 | pmid=23871090 | doi=10.1016/S0140-6736(13)60651-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23871090  }} </ref>


==References==
==References==


{{Reflist|2}}
{{Reflist|2}}

Revision as of 07:06, 9 January 2014

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Medical Therapy

Botulinum Toxin

Intra-sphincteric injection of botulinum toxin (or botox), to paralyze the lower esophageal sphincter and prevent spasms. As in the case of botox injected for cosmetic reasons, the effect is only temporary, and symptoms return quickly in most patients. Botox injections cause scarring in the sphincter which may increase the difficulty of later Heller myotomy.

Indications

  • For patients who cannot risk surgery
  • As an adjunct to myotomy to treat residual LES spasms

Mechanism of Action

  • BoTox acts as a zinc-dependant protease and cleaves a protein called SNAP-25. This results in a block of acetylcholine release from the presynaptic nerve terminal. As it is the excitatory neurons that release acetylcholine, a decrease in LES tone is observed.
  • It has also been shown that BoTox interferes with cholinergic signaling in the myenteric nervous system that supplies smooth muscle, and hence also decreases smooth muscle contractility.
  • Relief was associated with a reduction in LES pressure by 40%, an increase in esophageal diameter by 17%, and a reduction in esophageal retention of 33%.

Adverse Effects

  • BoTox is very well tolerated, and only ~ 5% develop symptomatic gastroesophageal reflux disease (GERD).
  • 16-25% rate of developing chest pain
  • Mediastinitis (rare)
  • Allergic reaction to egg protein (rare)
  • Higher rate of subsequent surgical complications
  • 50% relapse rate
  • Requirement for repeat injections (Pasricha et.al. showed that 90% of patients experienced immediate relief, however only 65% have relief at 6 months, and only 42% are symptom free at one year)[1][2][3]

Oral Pharmacotherapy

Drugs that reduce LES pressure may be useful, especially as a way to buy time while waiting for surgical treatment. Calcium channel blockers such as nifedipine, and long acting nitrates such as isosorbide dinitrate and nitroglycerin are the two most commonly used groups of medications.

Indications

  • Drugs are the least effective mode of treatment. They are used temporarily before the more effective mode of treatment such as pneumatic dilation and myotomy can be used and in high risk patients.

Mechanism of action

Adverse Effects

  • Headache
  • Hypotension
  • Pedal Edema
  • Usually only provide minimal relief.
  • As the pills themselves can get stuck in the esophagus, this can complicate the disease.

Other uncommon drugs which can be used in achalasia management: Sildenafil, Theophyllin, Atropine, Dicyclomine, Cimetropium Bromide, Terbutaline[2][3]

References

  1. ↑ Zhao X, Pasricha PJ (2003). "Botulinum toxin for spastic GI disorders: a systematic review". Gastrointest Endosc. 57 (2): 219–35. doi:10.1067/mge.2003.98. PMID 12556788.
  2. ↑ 2.0 2.1 Vaezi MF, Pandolfino JE, Vela MF (2013). "ACG clinical guideline: diagnosis and management of achalasia". Am J Gastroenterol. 108 (8): 1238–49, quiz 1250. doi:10.1038/ajg.2013.196. PMID 23877351.
  3. ↑ 3.0 3.1 Boeckxstaens GE, Zaninotto G, Richter JE (2014). "Achalasia". Lancet. 383 (9911): 83–93. doi:10.1016/S0140-6736(13)60651-0. PMID 23871090.
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