Medication Summary

Calcium channel blockers and nitrates both decrease lower esophageal sphincter (LES) pressure but do not improve LES relaxation. Approximately 10% of patients benefit from medical treatment, which should be used primarily in elderly patients who have contraindications to either pneumatic dilation or surgery or as a temporary measure while other treatments are considered.^[47]

Class Summary

These agents interfere with calcium uptake by smooth muscle cells that are dependent on intracellular calcium for contraction. They have a relaxant effect on the LES muscle.

Nifedipine (Adalat)

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Inhibits transmembrane influx of calcium ions into smooth muscle, which, in turn, inhibits contraction of the muscle fibers.

Class Summary

These agents relax vascular smooth muscle.

Isosorbide dinitrate (Isordil)

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Has a relaxant effect on smooth muscle fibers of LES. Relaxes vascular smooth muscle by stimulating intracellular cyclic GMP.

Questions

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Media Gallery

Achalasia. Barium swallow demonstrating the bird-beak appearance of the lower esophagus, dilatation of the esophagus, and stasis of barium in the esophagus.
Achalasia. Manometric evaluation of the esophagus in a patient with achalasia. Pertinent findings include absence of propulsive peristalsis in the body of the esophagus (note simultaneous contractions), elevated resting lower esophageal sphincter (LES) pressure, and the absence of LES relaxation.
Achalasia. Heller myotomy extending 1.5 cm onto the gastric wall.
Achalasia. Dor fundoplication, left row of sutures (after division of short gastric vessels).
Achalasia. Completed Dor fundoplication.
Achalasia. High-resolution manometry of patient with achalasia type I. Top one third (in purple) represents fluid-filled esophagus by impedance, with incomplete emptying between swallows. Below this, upper horizontal dark-red band represents upper esophageal sphincter; orange band at bottom with interspersed dark-red areas represents lower esophageal sphincter. In between these two bands, it can be noted that there is no panesophageal pressurization and no peristalsis in the esophageal body. Image courtesy of R Matthew Gideon, Albert Einstein Medical Center.
Achalasia. High-resolution manometry of patient with achalasia type II. Top one third (in purple) represents fluid-filled esophagus by impedance. Bottom two thirds (in orange) represents pressurized esophagus. Dark-red band at top of orange area represents upper esophageal sphincter (UES); dark-red band at bottom represents lower esophageal sphincter (LES). Note isobaric simultaneous contractions and elevated intraesophageal pressure (orange area) along with impaired LES relaxation (high resting pressure and incomplete relaxation). Image courtesy of R Matthew Gideon, Albert Einstein Medical Center.
Achalasia. High-resolution manometry of patient with achalasia type III. Top one third represents impedance portion of study. In bottom two thirds, in between orange horizontal bars representing upper and lower esophageal sphincters, vertical bands that represent esophageal body contractions can be seen. Note areas that are equivalent to spastic contraction, which can even obliterate esophageal lumen. Image courtesy of R Matthew Gideon, Albert Einstein Medical Center.