radiology lecture on achalasia
DESCRIPTION
Radiology Lecture on Achalasia by Dr. Saeed rad of radRounds.TRANSCRIPT
Feb 2009 SR1
LECTURE LECTURE ONON
ACHALASIAACHALASIA
S. RADS. RAD
With the cases from his own fileWith the cases from his own file
Tabriz University of Medical SciencesTabriz University of Medical SciencesTabriz-IranTabriz-Iran
TECHNIQUE OF EXAMINATIONTECHNIQUE OF EXAMINATION
Apart from clinical manometer no imaging Apart from clinical manometer no imaging modality compares to modality compares to fluoroscopic examination fluoroscopic examination with spot-filmingwith spot-filming for diagnosis of Achalasia.for diagnosis of Achalasia.
In fact any functional disorder in gastro-intestinal In fact any functional disorder in gastro-intestinal tract needs to be evaluated studying its state of tract needs to be evaluated studying its state of being in rest and moving modifications. being in rest and moving modifications. Fluoroscopy, an appropriate means to study Fluoroscopy, an appropriate means to study movements, can give functional data and is the movements, can give functional data and is the only one to be implemented for diagnosis in these only one to be implemented for diagnosis in these cases.cases.
Feb 2009 SR2
Feb 2009 SR3
MECHANISM OF PRODUCTIONMECHANISM OF PRODUCTION
Achalasia Achalasia aa negative version of negative version of chalasiachalasia ( wide open gastric cardia with ( wide open gastric cardia with facilitated gastro-esophageal reflux ) means facilitated gastro-esophageal reflux ) means non relaxation non relaxation of the of the sphincteric mechanism in the lower esophagus.sphincteric mechanism in the lower esophagus. Absence of the anatomical sphincter in the lower esophagus is Absence of the anatomical sphincter in the lower esophagus is compensated with the synergic action of multiple elements to play this compensated with the synergic action of multiple elements to play this role: role:
The acute angle of the entrance of the lower esophagus into the stomach The acute angle of the entrance of the lower esophagus into the stomach (namely angle of (namely angle of HisHis), hypertonic circular muscles of the lower esophagus ), hypertonic circular muscles of the lower esophagus by creating high pressure zone in this area, phrenico-esophageal membrane by creating high pressure zone in this area, phrenico-esophageal membrane (( Laimer’s Laimer’s) and freely to and fro moving of the esophageal vestibula in ) and freely to and fro moving of the esophageal vestibula in diaphragmatic hiatus surrounded by sling muscles of the diaphragmatic diaphragmatic hiatus surrounded by sling muscles of the diaphragmatic crura, All are collaborating to close the cardia in resting state with the crura, All are collaborating to close the cardia in resting state with the added effect of theadded effect of the gastrin gastrin content of the stomach or circulating one to content of the stomach or circulating one to produce tough closure of the cardia to prevent gastro-esophageal reflux. produce tough closure of the cardia to prevent gastro-esophageal reflux.
ETIOLOGYETIOLOGY
Cerebral cortex is the dominating commander of the esophageal function. Cerebral cortex is the dominating commander of the esophageal function. This is done by psychogenic effect or by cranial neural impact on the This is done by psychogenic effect or by cranial neural impact on the esophagus, specially vague or pneumo-gastric one (No X) via the esophagus, specially vague or pneumo-gastric one (No X) via the ambiguous nucleus of this nerve in the brain as the main factor. ambiguous nucleus of this nerve in the brain as the main factor. This nervous impulse is effectuated by myenteric plexus (This nervous impulse is effectuated by myenteric plexus (AuerbachAuerbach) of ) of the esophagus itself to autonomic movement of the organ.the esophagus itself to autonomic movement of the organ.According to the above-mentioned origins, achalasia may be due to :According to the above-mentioned origins, achalasia may be due to :-Psychogenic disturbance-Psychogenic disturbance-Vagal transmitting defect, such as seen in vagotomy or-Vagal transmitting defect, such as seen in vagotomy or Chagas Chagas disease.disease.-Lack of myenteric or autonomic nervous plexus of the esophagus itself.-Lack of myenteric or autonomic nervous plexus of the esophagus itself.
Feb 2009 SR4
The very first sign of the achalasia is the apparition of retention of fluid in its lumen which normally takes no more than 5 or 6 second to empty, subsequently a fluid level in the esopghagus is not seen in standing position, where the gravity should accelerate the stripping function of the organ.To notice this phenomenon it is mandatory to start examination in erect or upright position. This is just the opposite of esophageal involvement in scleroderma ( progressive systemic sclerosis) which demands examination in lying down position to suppress the gravity action of the stagnating fluid to notice the peristalsis only.
Feb 2009 SR5
Air bubble of the stomach is produced by aerophagia or swallowed Air bubble of the stomach is produced by aerophagia or swallowed air. In the case of achalasia stagnation of the fluid inside esophagus air. In the case of achalasia stagnation of the fluid inside esophagus prevents air to reach the stomach and so, lack of gastric air bubble or prevents air to reach the stomach and so, lack of gastric air bubble or its diminution may be another important sign of the insult.its diminution may be another important sign of the insult.
Feb 20096 SR
Achalasia may be seen at the level of the crico-pharyngeus muscle, called superior achalasia or at the lower end, the ordinary lower achalasia. In any case it is produced by non-relaxation of the sphincters, upper one been a true or anatomical sphinter ( crico-pharyngeus muscle) and a sphincteric mechanism in lower end or sometimes anatomical caused by non-relaxation of the crura sling muscle.A special type of this disorder may also be seen and caused by secondary obtruding factors of the cardia in fact pseudo-achalasia, a justified nomenclature.
Feb 2009 SR7
Feb 2009 SR8Pharyngeal achalasiaPharyngeal achalasia
Feb 2009 SR9
Cricopharyngeus or Cricopharyngeus or UESUES
There are no stripping There are no stripping waveswaves and inactive peristalsis is and inactive peristalsis is
not able to evacuate not able to evacuate esophagus . esophagus . Tubular
esophagus or Ring A is located where the muscular
part transforms to the vestibular region and non-relaxation of the lower end
of the organ affects this point . That is why the
lower end of the esophagus in achalasia appears conical
( Bird’s beak) caused by contractile state of the
circular muscles.Feb 200910 SR
Conical and Conical and concentric tapering concentric tapering
of the lower of the lower esophagus stands esophagus stands just at the cardia.just at the cardia.
Conical and Conical and concentric tapering concentric tapering
of the lower of the lower esophagus stands esophagus stands just at the cardia.just at the cardia.
Feb 200911 SR
Persistent retention Persistent retention because of the inactive because of the inactive
stripping waves stripping waves despite their force in:despite their force in:
Vigorous achalasia.Vigorous achalasia.
Persistent retention Persistent retention because of the inactive because of the inactive
stripping waves stripping waves despite their force in:despite their force in:
Vigorous achalasia.Vigorous achalasia.
Feb 200912 SR
Vigorous achalasia.Vigorous achalasia.Vigorous achalasia.Vigorous achalasia.
Feb 200913 SR
With previous operation ( Heller type ) there With previous operation ( Heller type ) there is usually a diverticulum formation at the is usually a diverticulum formation at the
cardia.cardia.
With previous operation ( Heller type ) there With previous operation ( Heller type ) there is usually a diverticulum formation at the is usually a diverticulum formation at the
cardia.cardia.Feb 200914 SR
Deformity due to the Deformity due to the previous operation.previous operation.
Deformity due to the Deformity due to the previous operation.previous operation.
Feb 200915 SR
Before and after operation.Before and after operation.
Inefficient operation in advanced cases.Inefficient operation in advanced cases.
Before and after operation.Before and after operation.
Inefficient operation in advanced cases.Inefficient operation in advanced cases.Feb 200916 SR
Huge epiphrenic Huge epiphrenic diverticulum is the rule diverticulum is the rule
in achalasia.in achalasia.
Huge epiphrenic Huge epiphrenic diverticulum is the rule diverticulum is the rule
in achalasia.in achalasia.Feb 200917 SR
Food retention in epiphrenic diverticulum.Food retention in epiphrenic diverticulum.Food retention in epiphrenic diverticulum.Food retention in epiphrenic diverticulum.
Feb 200918 SR
Double epiphrenic Double epiphrenic diverticulum.diverticulum.
Sorry for the patient’s Sorry for the patient’s fore-arm inadvertently fore-arm inadvertently overlapping the lower overlapping the lower end of the esophagus!end of the esophagus!
Double epiphrenic Double epiphrenic diverticulum.diverticulum.
Sorry for the patient’s Sorry for the patient’s fore-arm inadvertently fore-arm inadvertently overlapping the lower overlapping the lower end of the esophagus!end of the esophagus!
Feb 200919 SR
Huge epiphrenic diverticulum Huge epiphrenic diverticulum simulatingsimulating
Heart filled up with food!Heart filled up with food!
Huge epiphrenic diverticulum Huge epiphrenic diverticulum simulatingsimulating
Heart filled up with food!Heart filled up with food!
Feb 200920 SR
Diverticulum in achalasia simulating lung tumor.Diverticulum in achalasia simulating lung tumor.Diverticulum in achalasia simulating lung tumor.Diverticulum in achalasia simulating lung tumor.
Feb 200921 SR
Achalasia demonstrated in Achalasia demonstrated in chest CT, only a chest CT, only a
morphological evaluationmorphological evaluation
Achalasia demonstrated in Achalasia demonstrated in chest CT, only a chest CT, only a
morphological evaluationmorphological evaluation
Feb 200922 SR
Fluid level in Fluid level in the the
esophagus.esophagus.
In CT and In CT and barium barium
study. Bird’s study. Bird’s beak sign beak sign may be may be
shown only shown only in in
reformatting reformatting coronal coronal
aspect with aspect with MDCTMDCT
Fluid level in Fluid level in the the
esophagus.esophagus.
In CT and In CT and barium barium
study. Bird’s study. Bird’s beak sign beak sign may be may be
shown only shown only in in
reformatting reformatting coronal coronal
aspect with aspect with MDCTMDCTFeb 200923 SR
Achalasia with unusual diverticulum simulating neural Achalasia with unusual diverticulum simulating neural tumor.tumor.
Achalasia with unusual diverticulum simulating neural Achalasia with unusual diverticulum simulating neural tumor.tumor.
Feb 200924 SR
CTs of the same patientCTs of the same patient
Feb 200925 SR
Deviation of dilated Deviation of dilated esophagus to the right esophagus to the right
side:side:
Men’s socks Men’s socks appearanceappearance
Deviation of dilated Deviation of dilated esophagus to the right esophagus to the right
side:side:
Men’s socks Men’s socks appearanceappearance
Feb 200926 SR
Men’s socks appearance.Men’s socks appearance.Men’s socks appearance.Men’s socks appearance.
Feb 200927 SR
No relevant chest x-ray. There are always exceptions for the rules!
No relevant chest x-ray. There are always exceptions for the rules!
Feb 200928 SR
Paraffinoma due Paraffinoma due to the oil ingestion to the oil ingestion
in achalasia to in achalasia to facilitate facilitate
swallowing in swallowing in some way. some way.
Paraffinoma due Paraffinoma due to the oil ingestion to the oil ingestion
in achalasia to in achalasia to facilitate facilitate
swallowing in swallowing in some way. some way.
Feb 200929 SR
Esophageal wall Esophageal wall seen on the top of seen on the top of
the mediastinal the mediastinal widening is in widening is in
favor of achalasia.favor of achalasia.
Esophageal wall Esophageal wall seen on the top of seen on the top of
the mediastinal the mediastinal widening is in widening is in
favor of achalasia.favor of achalasia.
Feb 200930 SR
Operated thoracic Operated thoracic transferred stomach transferred stomach usually presents a usually presents a
thick wall and thick wall and should not be should not be confused with confused with
achalasia.achalasia.
Operated thoracic Operated thoracic transferred stomach transferred stomach usually presents a usually presents a
thick wall and thick wall and should not be should not be confused with confused with
achalasia.achalasia.
Feb 200931 SR
Odd pattern of the filled up thoracic stomach caused by Odd pattern of the filled up thoracic stomach caused by narrowing of the pylorus or tight hiatus not widened narrowing of the pylorus or tight hiatus not widened
during operation.during operation.
Odd pattern of the filled up thoracic stomach caused by Odd pattern of the filled up thoracic stomach caused by narrowing of the pylorus or tight hiatus not widened narrowing of the pylorus or tight hiatus not widened
during operation.during operation.Feb 200932 SR
Lung abscess simulating cavitating malignancy due to Lung abscess simulating cavitating malignancy due to perforate achalasia. perforate achalasia. Notice fluid level in the esophagus at Notice fluid level in the esophagus at the plain film, best sign for fluid stagnation.the plain film, best sign for fluid stagnation.
Lung abscess simulating cavitating malignancy due to Lung abscess simulating cavitating malignancy due to perforate achalasia. perforate achalasia. Notice fluid level in the esophagus at Notice fluid level in the esophagus at the plain film, best sign for fluid stagnation.the plain film, best sign for fluid stagnation.
Feb 200933 SR
Lung or mediastinal abscess caused by perforated Lung or mediastinal abscess caused by perforated achalasia.achalasia.
Lung or mediastinal abscess caused by perforated Lung or mediastinal abscess caused by perforated achalasia.achalasia.
Feb 200934 SR
Lung abscess caused by Lung abscess caused by repeated aspiration in repeated aspiration in
achalasia.achalasia. Notice: Notice: esophageal wall in esophageal wall in mediastinum and mediastinum and
absence of gastric air absence of gastric air bubble.bubble.
Lung abscess caused by Lung abscess caused by repeated aspiration in repeated aspiration in
achalasia.achalasia. Notice: Notice: esophageal wall in esophageal wall in mediastinum and mediastinum and
absence of gastric air absence of gastric air bubble.bubble.
Feb 200935 SR
Pseudo-achalasia due to tumor infiltration of the cardiaPseudo-achalasia due to tumor infiltration of the cardia ..Pseudo-achalasia due to tumor infiltration of the cardiaPseudo-achalasia due to tumor infiltration of the cardia ..Feb 200936 SR
Different Different cases of cases of pseudo-pseudo-
achalasia.achalasia.
Different Different cases of cases of pseudo-pseudo-
achalasia.achalasia.
Feb 200937 SR
Pseudo-achalasia diagnosed in plain abdominal Pseudo-achalasia diagnosed in plain abdominal film.film.
Pseudo-achalasia diagnosed in plain abdominal Pseudo-achalasia diagnosed in plain abdominal film.film.Feb 200938 SR
Achalasia may occur in Achalasia may occur in children as well:children as well:
One-year-old childOne-year-old child
Achalasia may occur in Achalasia may occur in children as well:children as well:
One-year-old childOne-year-old child
One and half-year-oldOne and half-year-oldOne and half-year-oldOne and half-year-old
Feb 200939 SR
Four-year-oldFour-year-oldFour-year-oldFour-year-old
Seven-year-old Seven-year-old Seven-year-old Seven-year-old
Feb 200940 SR
Twelve-year-old Twelve-year-old child having child having trouble since trouble since
infancy.infancy.
Twelve-year-old Twelve-year-old child having child having trouble since trouble since
infancy.infancy.
Feb 200941 SR
Onset of malignancy Onset of malignancy in long standing in long standing
achalasia.achalasia.
Onset of malignancy Onset of malignancy in long standing in long standing
achalasia.achalasia.
Ninety-year-old patientNinety-year-old patient
Tumor occurrence is almost always above the cardiaTumor occurrence is almost always above the cardia
Feb 200942 SR
Malignancy is located almost always above the cardia.Malignancy is located almost always above the cardia.Malignancy is located almost always above the cardia.Malignancy is located almost always above the cardia.Feb 200943 SR
ConclusionConclusionConclusionConclusionAchalasia may be guessed by the absence Achalasia may be guessed by the absence
of the gastric air bubble on the chest x-rays of the gastric air bubble on the chest x-rays in clinically suspicious settings. There is no in clinically suspicious settings. There is no air-fluid level seen on the plain film of the air-fluid level seen on the plain film of the normal esophagus and its apparition is in normal esophagus and its apparition is in
favor of achalasia in most of the cases with favor of achalasia in most of the cases with mediastinal widening. Conical and mediastinal widening. Conical and
concentric tapering of the cardia with concentric tapering of the cardia with reservation of the normal mucosal pattern reservation of the normal mucosal pattern confirms the diagnosis of the achalasia.confirms the diagnosis of the achalasia.
Achalasia may be guessed by the absence Achalasia may be guessed by the absence of the gastric air bubble on the chest x-rays of the gastric air bubble on the chest x-rays in clinically suspicious settings. There is no in clinically suspicious settings. There is no air-fluid level seen on the plain film of the air-fluid level seen on the plain film of the normal esophagus and its apparition is in normal esophagus and its apparition is in
favor of achalasia in most of the cases with favor of achalasia in most of the cases with mediastinal widening. Conical and mediastinal widening. Conical and
concentric tapering of the cardia with concentric tapering of the cardia with reservation of the normal mucosal pattern reservation of the normal mucosal pattern confirms the diagnosis of the achalasia.confirms the diagnosis of the achalasia.
Feb 200944 SR
Feb 200945 SR
THE END