Problem 1

Gastrointestinal System Block

Vinnie Charlita Leonardo
405140192
 Learning Objective 1
Anatomy of Upper GIT
 Learning Objective 2
Histology of Upper GIT
 Digestive Tract

Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
 General Structure of The Digestive
Tract

Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
Oral cavity: lip

Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
Tongue, Lingual Pappilae, Taste Buds

Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
 Lingual Pappilae

Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
 Teeth

Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
 Esophagus

Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
 Esophagus

Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
 Organ Associated with The Digestive
Tract : Salivary Gland

Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
Mescher AL. Junqueira’s basic histology text & atlas.13th Edition. US: McGraw-Hill Education; 2013.
 Learning Objective 3
Physiology of Upper GIT
Sherwood L. Human physiology: from cell to systems. 9th Ed.
 Control of Saliva Secretion

Sherwood L. Human physiology: from cell to systems. 9th Ed.

 Swallowing

Sherwood L. Human physiology: from cell to systems. 9th Ed.

Tortora GJ, Derrickson B. Principles of anatomy and physiology. 12th Edition. US: John Willey & Sons; 2009.
Tortora GJ, Derrickson B. Principles of anatomy and physiology. 12th Edition. US: John Willey & Sons; 2009.
Tortora GJ, Derrickson B. Principles of anatomy and physiology. 12th Edition. US: John Willey & Sons; 2009.
Tortora GJ, Derrickson B. Principles of anatomy and physiology. 12th Edition. US: John Willey & Sons; 2009.
 Learning Objective 4
Biochemistry of Upper GIT
 Digestive Enzymes

Tortora GJ, Derrickson B. Principles of anatomy and physiology. 12th Edition. US: John Willey & Sons; 2009.
 Digestive Enzymes

Tortora GJ, Derrickson B. Principles of anatomy and physiology. 12th Edition. US: John Willey & Sons; 2009.
 Learning Objective 5
Dysphagia & Odynophagia
 Dysphagia
 Difficulty swallowing
 It takes more time and effort to move food or liquid from
mouth to stomach.
 Dysphagia can be secondary to defects in any of the 3
phases of swallowing, which are as follows :
 Oral phase: Which involves the oral preparatory phase and the
oral transit phase
 Pharyngeal phase
 Esophageal phase

http://emedicine.medscape.com/article/2212409-overview#a3
 Oral Phase
 The oral phase of swallowing is divided into the following
2 parts:
 Oral preparatory phase: The processing of the bolus to render
it swallowable
 Oral propulsive (or transit) phase: The propelling of food from
the oral cavity into the oropharynx

http://emedicine.medscape.com/article/2212409-overview#a4
 Oral Preparatory Phase
 The process begins with contractions of the tongue and
striated muscles of mastication.
 The muscles work in a coordinated fashion to mix the
food bolus with saliva, with the taste, temperature, touch,
and proprioception senses required to form a bolus of
the right size and consistency.

http://emedicine.medscape.com/article/2212409-overview#a4
 Oral Propulsive (or Transit) Phase
 The swallowing process involves manipulation of the bolus
formed in the preparatory stage in the central portion of the
tongue.
 The bolus  the pharynx posteriorly with a sequential
anterior-to-posterior tongue elevation in order to trigger the
swallowing reflex as the bolus Enters the pharyngeal phase.

http://emedicine.medscape.com/article/2212409-overview#a4
 Pharyngeal Phase
 The pharyngeal phase is of particular importance, Because
without intact laryngeal protective mechanisms, aspiration (the
passage of food or liquid through the vocal folds) is most likely
to occur during this phase.
 This phase involves a rapid sequence of overlapping events. The
soft palate rises, the hyoid bone and larynx move upward and
forward, the vocal folds move to the midline, the epiglottis
folds backward to protect the airway, and the tongue pushes
backward and downward into the pharynx to propel the bolus
downward. The tongue is assisted by the pharyngeal walls, the
which move inward with a progressive wave of contraction
from top to bottom.

http://emedicine.medscape.com/article/2212409-overview#a4
 Pharyngeal Phase
 The upper esophageal sphincter relaxes during the
pharyngeal phase of swallowing and is pulled open by the
forward movement of the hyoid bone and larynx. This
sphincter closes after passage of the food, and the
pharyngeal structures then return to the reference
position.

http://emedicine.medscape.com/article/2212409-overview#a4
 Esophageal phase
 The bolus is propelled downward by a peristaltic
movement. The lower esophageal sphincter relaxes at initiation
of the swallow, and this relaxation persists until the food bolus
has been propelled into the stomach.
 The lower sphincter is not pulled open by extrinsic
musculature. Rather, it closes after the bolus Enters the
stomach, thereby Preventing gastroesophageal reflux
 The medulla controls this involuntary swallowing reflex,
voluntary Although swallowing may be initiated by the cerebral
cortex.

http://emedicine.medscape.com/article/2212409-overview#a4
 Etiology of Dysphagia
 Central nervous system disorders
 Muscular disorders
 Neuropathic disorders
 Endocrine disorders
 Pharmacologic causes
 Motility disorders
 Esophagitis
 Structural disorders

http://emedicine.medscape.com/article/2212409-overview#a6
 Epidemiology
 Stroke is the leading cause of neurologic dysphagia, with
the condition occurring in Approximately 51-73% of
patients with stroke.
 According to the US National Medicare database, the
incidence of poststroke dysphagia is higher in Asians and
other minority groups than in whites, suggesting racial
disparities in the development of dysphagia after stroke.
 The prevalence of dysphagia increases with age, and
dysphagia is a major health care problem in elderly
patients.

http://emedicine.medscape.com/article/2212409-overview#a7
 Pathophysiology
 A lesion in the cerebral cortex or the brainstem can
cause swallowing disorders as a result of the following:
 Decrease in range of motion (ROM) of muscles of mastication
and bolus propulsion, especially those responsible for buccal,
labial, and lingual strength and the cricopharyngeus
 Decreased sensation
 Delayed or absent pharyngeal swallowing and reductions in
pharyngeal peristalsis
 Delayed or absent laryngeal adduction and elevation

http://emedicine.medscape.com/article/2212409-overview#a5
 Oral Phase Disorders
 Logemann's Manual for the Videofluorographic Study of
Swallowing cites the following oral-phase swallowing
symptoms and disorders:
 Inability to hold food in the mouth anteriorly due to reduced
lip closure
 Inability to form a bolus or residue on the floor of the mouth
due to reduced range of tongue motion or coordination
 Inability to hold a bolus due to reduced tongue shaping and
coordination
 Inability to align teeth due to reduced mandibular movement
 Entry of food material into the anterior sulcus or the presence
of residue in the anterior sulcus due to reduced labial tension
or tone

http://emedicine.medscape.com/article/2212409-overview#a5
  Entry of food material into the lateral sulcus or the presence
of residue in the lateral sulcus due to reduced buccal tension
or tone
 Abnormal hold position or dropping of material to the floor of
the mouth due to tongue thrust or reduced tongue control
 Delayed oral onset of swallow due to apraxia of swallow or
reduced oral sensation
 Searching motion or inability to organize tongue movements
due to apraxia of swallow
 Forward tongue movement to start the swallow due to tongue
thrust
 Residue of food on the tongue due to reduced tongue range of
movement or strength

http://emedicine.medscape.com/article/2212409-overview#a5
  Disturbed lingual contraction (peristalsis) due to lingual
discoordination
 Incomplete tongue-to-palate contact due to reduced tongue
elevation
 Inability to mash material due to reduced tongue elevation
 Adherence of food to hard palate due to reduced tongue elevation
or reduced lingual strength
 Reduced anterior-posterior lingual action due to reduced lingual
coordination
 Repetitive lingual rolling in Parkinson disease
 Uncontrolled bolus or premature loss of liquid or pudding
consistency into the pharynx due to reduced tongue control or
linguavelar seal
 Piecemeal deglutition
 Delayed oral transit time

http://emedicine.medscape.com/article/2212409-overview#a5
 Pharyngeal Phase Disorders
 If pharyngeal clearance is severely impaired, a patient may
be unable to ingest sufficient amounts of food and drink
to sustain life. In people without dysphasia, small amounts
of food commonly are retained in the valleculae or
pyriform sinus after swallowing. If there is weakness in or
a lack of coordination of the pharyngeal muscles or if
there is a poor opening of the upper esophageal
sphincter, patients may retain excessive amounts of food
in the pharynx and experience overflow aspiration after
swallowing.
 Dysfunction or abnormalities of the soft palate and
superior pharynx (eg, cleft palate) can lead to
nasopharyngeal reflux following uvulectomy

http://emedicine.medscape.com/article/2212409-overview#a5
 Pharyngeal Phase Disorders
 Logemann's Manual for the Videofluorographic Study of
Swallowing cites the following pharyngeal-phase
swallowing symptoms and disorders :
 Delayed pharyngeal swallow
 Nasal penetration during swallow due to reduced
velopharyngeal closure
 Pseudoepiglottis (after total laryngectomy): Fold of mucosa at
the base of the tongue
 Cervical osteophytes
 Coating of pharyngeal walls after the swallow due to bilateral
reduction of pharyngeal contraction

http://emedicine.medscape.com/article/2212409-overview#a5
  Vallecular residue due to reduced posterior movement of the
tongue base
 Coating in a depression on the pharyngeal wall due to scar
tissue or pharyngeal pouch
 Residue at top of airway due to reduced laryngeal elevation
 Laryngeal penetration and aspiration due to reduced closure of
the airway entrance (arytenoid to base of epiglottis)
 Aspiration during swallow due to reduced laryngeal closure
 Stasis of residue in pyriform sinuses due to reduced anterior
laryngeal pressure
 Delayed pharyngeal transit time

http://emedicine.medscape.com/article/2212409-overview#a5
 Esophageal Phase Disorders
 Impaired esophageal function can result in retention of food
and liquid in the esophagus after swallowing. This retention
may result from a mechanical obstruction, a motility disorder,
or an impairment of the opening of the lower esophageal
sphincter.
 Achalasia can lead to reduced gastroesophageal junction
relaxation or absent esophageal peristalsis
 Other defects in the wall of the esophagus or in the external
structures (eg, in the hilar lymph nodes) can lead to
dysfunction in the propulsion of the bolus from the esophagus
to the stomach (eg, esophageal webs, rings, strictures;
intraluminal obstruction from solids) and result in weak
esophagopharyngeal peristalsis due to scleroderma or other
conditions

http://emedicine.medscape.com/article/2212409-overview#a5
 Esophageal Phase Disorders
 Logemann's Manual for the Videofluorographic Study of
Swallowing cites the following swallowing symptoms and
disorders of the esophageal phase :
 Esophageal-to-pharyngeal backflow due to esophageal
abnormality
 Tracheoesophageal fistula
 Zenker diverticulum
 Reflux

http://emedicine.medscape.com/article/2212409-overview#a5
Longo DL, Fauci AS. Harrison’s gastroenterology & hepatology. 2010
 Odynophagia
 Odynophagia is pain either caused by or exacerbated by
swallowing
 Odynophagia is more common with pill or infectious
esophagitis than with reflux esophagitis and should
prompt a search for these entities
 When odynophagia does occur in GERD, it is likely
related to an esophageal ulcer or deep erosion
Learning Objective 6
Upper GIT Disorders
Mouth Ulcers
 Mouth Ulcers
 Mouth ulcers are sores or open lesions in the mouth.
 Mouth ulcers are caused by many disorders. These
include:
 Canker sores
 Gingivostomatitis
 Herpes simplex (fever blister)
 Leukoplakia
 Oral cancer
 Oral lichen planus
 Oral thrush
 A skin sore caused by histoplasmosis may also appear as a
mouth ulcer.

https://medlineplus.gov/ency/article/001448.htm
 Symptomps Treatment

 Open sores in the mouth  The underlying cause of the

ulcer should be treated if it is
 Pain or discomfort in the known.
mouth  Gently cleaning mouth and
teeth may help relieve
symptoms.
 Medicines that rub directly on
the ulcer such as
antihistamines, antacids, and
corticosteroids may help
soothe discomfort.
 Avoid hot or spicy foods until
the ulcer is healed

https://medlineplus.gov/ency/article/001448.htm
 Prognosis
 The outcome varies
depending on the cause of
the ulcer. Many mouth
ulcers are harmless and
heal without treatment.
 Some types of cancer may
first appear as a mouth
ulcer that does not heal.
https://medlineplus.gov/ency/article/001448.htm
Complication
 Cellulitis of the mouth,
from secondary bacterial
infection of ulcers
 Dental infections (tooth
abscesses)
 Oral cancer
 Spread of contagious
disorders to other people
 Prevention
 Brush teeth at least twice a day and floss once a day.
 Get regular dental cleanings and checkups.

https://medlineplus.gov/ency/article/001448.htm
Candidiasis
 Candidiasis
 a fungal infection caused by yeasts that belong to the
genus Candida.
 There are over 20 species of Candida yeasts that can
cause infection in humans, the most common of which
is Candida albicans.

Soreness and cracks at the lateral angles of the

mouth (angular cheilitis) are a frequent
expression of candidiasis in elderly individuals.
Courtesy of Matthew C. Lambiase, DO.
https://www.cdc.gov/fungal/diseases/candidiasis/
 Epidemiology
 Persons at the extremes of age (neonates and adults >65
years) are most susceptible to candidal colonization.
 Very-low-birth-weight and extremely-low-birth-weight
infants are at high risk for blood culture–proven late-
onset candidiasis (defined as sepsis that develops after age
72 h).

http://emedicine.medscape.com/article/213853-overview#a8
 Pathophysiology
 Candida species contain their own set of well-recognized
but not well-characterized virulence factors that may
contribute to their ability to cause infection.
 The main virulence factors include the following:
 Surface molecules that permit adherence of the organism to
other structures (eg, human cells, extracellular matrix,
prosthetic devices)
 Acid proteases and phospholipases that involve penetration
and damage of cell envelopes
 Ability to convert to a hyphal form (phenotypic switching)

http://emedicine.medscape.com/article/213853-overview#showall
 Host defense mechanisms against Candida infection and their
associated defects that allow infection are as follows:
 Intact mucocutaneous barriers - Wounds, intravenous catheters,
burns, ulcerations
 Phagocytic cells -Granulocytopenia
 Polymorphonuclear leukocytes - Chronic granulomatous disease
 Monocytic cells -Myeloperoxidase deficiency
 Complement -Hypocomplementemia
 Immunoglobulins -Hypogammaglobulinemia
 Cell-mediated immunity - Chronic mucocutaneous candidiasis,
diabetes mellitus, cyclosporin A, corticosteroids, HIV infection
 Mucocutaneous protective bacterial flora - Broad-spectrum
antibiotics

http://emedicine.medscape.com/article/213853-overview#showall
 Risk Factors
 Granulocytopenia  Recent chemotherapy or
 Bone marrow radiation therapy
transplantation  Corticosteroids
 Solid organ  Broad-spectrum
transplantation (liver, antibiotics
kidney)  Burns
 Parenteral  Prolonged hospitalization
hyperalimentation  Severe trauma
 Hematologic malignancies  Recent bacterial infection
 Foley catheters  Recent surgery
 Solid neoplasms
http://emedicine.medscape.com/article/213853-overview#showall
 Risk Factors
 Gastrointestinal tract
surgery
 Central intravascular
access devices
 Premature birth
 Hemodialysis
 Acute and chronic renal
failure
 Mechanical ventilation for
longer than 3 days

http://emedicine.medscape.com/article/213853-overview#showall
 Signs & Symptoms
 Chronic mucocutaneous candidiasis
 Findings reveal disfiguring lesions of the face, scalp, hands, and
nails. Chronic mucocutaneous candidiasis is occasionally
associated with oral thrush and vitiligo.

http://emedicine.medscape.com/article/213853-overview#showall
 Signs & Symptoms
 Oropharyngeal candidiasis
Individuals with oropharyngeal candidiasis (OPC) usually have
a history of HIV infection, wear dentures, have diabetes
mellitus, or have been exposed to broad-spectrum antibiotics
or inhaled steroids. Although patients are frequently
asymptomatic, when symptoms do occur, they can include the
following:
 Sore and painful mouth
 Burning mouth or tongue
 Dysphagia
 Thick, whitish patches on the oral mucosa

 Physical examination reveals a diffuse erythema and white

patches that appear on the surfaces of the buccal mucosa,
throat, tongue, and gums.

http://emedicine.medscape.com/article/213853-overview#showall
 Signs & Symptoms
 The following are the 5 types of OPC:
 Membranous candidiasis - One of the most common types;
characterized by creamy-white, curdlike patches on the
mucosal surfaces
 Chronic atrophic candidiasis (denture stomatitis) - Also
thought to be one of the most common forms of the disease;
presenting signs and symptoms include chronic erythema and
edema of the portion of the palate that comes into contact
with dentures
 Erythematous candidiasis - Associated with an erythematous
patch on the hard and soft palates
 Angular cheilitis - Inflammatory reaction characterized by
soreness, erythema, and fissuring at the corners of the mouth
 Mixed - A combination of any of the above types is possible

http://emedicine.medscape.com/article/213853-overview#showall
 Signs & Symptoms
Nonesophageal
Esophageal Candidiasis
Gastrointestinal Candidiasis
 Patients with esophageal
candidiasis may be  Epigastric pain
asymptomatic or may have 1 or
more of the following  Nausea and vomiting
symptoms:  Abdominal pain
 Normal oral mucosa (>50% of
patients)  Fever and chills
 Dysphagia
 Odynophagia  Abdominal mass (in some
 Retrosternal pain cases)
 Epigastric pain
 Nausea and vomiting
 Physical examination almost
always reveals oral candidiasis

http://emedicine.medscape.com/article/213853-overview#showall
 Signs & Symptoms
 Genitourinary tract candidiasis
The types of genitourinary tract candidiasis are as follows:
 Vulvovaginal candidiasis (VVC) - Erythematous vagina and labia; a
thick, curdlike discharge; and a normal cervix upon speculum
examination
 Candida balanitis - Penile pruritus and whitish patches on the penis
 Candida cystitis - Many patients are asymptomatic, but bladder
invasion may result in frequency, urgency, dysuria, hematuria, and
suprapubic pain
 Asymptomatic candiduria - Most catheterized patients with
persistent candiduria are asymptomatic
 Ascending pyelonephritis - Flank pain, abdominal cramps, nausea,
vomiting, fever, chills and hematuria
 Fungal balls - Intermittent urinary tract obstruction with subsequent
anuria and ensuing renal insufficiency

http://emedicine.medscape.com/article/213853-overview#showall
 Diagnosis
 Mucocutaneous candidiasis - For a wet mount, scrapings or
smears obtained from skin, nails, or oral or vaginal mucosa are
examined under the microscope; a potassium hydroxide smear,
Gram stain, or methylene blue is useful for direct
demonstration of fungal cells
 Cutaneous candidiasis - Using a wet mount, scrapings or
smears obtained from skin or nails can be examined under the
microscope; potassium hydroxide smears are also useful
 Genitourinary candidiasis - A urinalysis should be performed;
evidence of white blood cells (WBCs), red blood cells (RBCs),
protein, and yeast cells is common; urine fungal cultures are
useful
 Gastrointestinal candidiasis - Endoscopy with or without biops

http://emedicine.medscape.com/article/213853-overview#showall
 Management
 Cutaneous candidiasis - Most localized cutaneous candidiasis
infections can be treated with any number of topical antifungal
agents (eg, clotrimazole, econazole, ciclopirox, miconazole,
ketoconazole, nystatin)
 Chronic mucocutaneous candidiasis - This condition is generally
treated with oral azoles
 Oropharyngeal candidiasis - This can be treated with either topical
antifungal agents or systemic oral azoles
 Esophageal candidiasis - Treatment requires systemic therapy with
fluconazole
 VVC - Topical antifungal agents or oral fluconazole can be used [4]
 Candida cystitis - In noncatheterized patients, Candida cystitis should
be treated with fluconazole; in catheterized patients, the Foley
catheter should be removed or replaced; if the candiduria persists
after the catheter change, then patients can be treated with
fluconazole

http://emedicine.medscape.com/article/213853-overview#showall
Achalasia
 Achalasia
 Achalasia is a primary esophageal motility disorder
characterized by the absence of esophageal peristalsis and
impaired relaxation of the lower esophageal sphincter
(LES) in response to swallowing.
 The LES is hypertensive in about 50% of patients.
 These abnormalities cause a functional obstruction at the
gastroesophageal junction (GEJ).

http://reference.medscape.com/article/169974-overview
 Epidemiology
 The incidence of achalasia is approximately 1 per 100,000
people per year.
 The incidence of esophageal dysmotility appears to
increased in patients with spinal cord injury (SCI).
 The male-to-female ratio of achalasia is 1:1.
 Achalasia typically occurs in adults aged 25-60 years. Less
than 5% of cases occur in children.

http://reference.medscape.com/article/169974-overview#a2
 Etiology
 Achalasia primer : unknown cause. Allegedly caused by
neurotropic viruses that cause lesions in the dorsal vagal
nucleus in the brain stem and ganglia misenterikus
esophagus.
 Achalasia sekunder : can be caused by infection (eg cagas
disease), tumor intraluminer like cardia tumors or extra
encouragement luminaire as pancreatic pseudocyst.
Another possibility could be caused by an anticholinergic
drug or post vagotomi.

Buku Ilmu Penyakit Dalam. Hal:1743-1744.

 Pathophysiology
 LES pressure and relaxation are regulated by excitatory
(eg, acetylcholine, substance P) and inhibitory (eg, nitric
oxide, vasoactive intestinal peptide) neurotransmitters.
Persons with achalasia lack nonadrenergic, noncholinergic,
inhibitory ganglion cells, causing an imbalance in
excitatory and inhibitory neurotransmission.The result is
a hypertensive nonrelaxed esophageal sphincter.

http://reference.medscape.com/article/169974-overview#a6
 Sign & Symptoms
 Backflow (regurgitation) of food
 Chest pain, which may increase after eating, or may be felt
as pain in the back, neck, and arms
 Cough
 Difficulty swallowing liquids and solids
 Heartburn
 Unintentional weight loss

https://medlineplus.gov/ency/article/000267.htm
 Diagnosis
 Barium swallow: Bird’s beak appearance, esophageal
dilatation
 Esophageal manometry (the criterion standard):
Incomplete LES relaxation in response to swallowing, high
resting LES pressure, absent esophageal peristalsis
 Prolonged esophageal pH monitoring to rule out
gastroesophageal reflux disease and determine if
abnormal reflux is being caused by treatment
 Esophagogastroduodenoscopy to rule out cancer of the
GEJ or fundus
 Concomitant endoscopic ultrasonography if a tumor is
suspected

http://reference.medscape.com/article/169974-overview#a1
 Diagnosis

 Barium swallow demonstrating the bird-beak

appearance of the lower esophagus, dilatation
of the esophagus, and stasis of barium in the
esophagus
http://reference.medscape.com/article/169974-overview#a1
 Management
 The goal of therapy for achalasia is to relieve symptoms
by eliminating the outflow resistance caused by the
hypertensive and nonrelaxing LES.
 Pharmacologic and other nonsurgical treatments include
the following:
 Administration of calcium channel blockers and nitrates
decrease LES pressure (primarily in elderly patients who cannot
undergo pneumatic dilatation or surgery)
 Endoscopic intrasphincteric injection of botulinum toxin to
block acetylcholine release at the level of the LES (mainly in
elderly patients who are poor candidates for dilatation or
surgery)

http://reference.medscape.com/article/169974-overview#a1
 Management
 Surgical treatment includes the following:
 Laparoscopic Heller myotomy, preferably with anterior (Dor;
more common) or posterior (Toupet) partial fundoplication
 Peroral endoscopic myotomy (POEM)
 Patients in whom surgery fails may be treated with an
endoscopic dilatation first.
 If this fails, a second operation can be attempted once the
cause of failure has been identified with imaging studies.
Esophagectomy is the last resort.

http://reference.medscape.com/article/169974-overview#a1
 Prognosis Complication

 The outcomes of surgery  Backflow (regurgitation) of

& non-surgical treatments acid or food from the
are similar. More than one stomach into the
treatment is sometimes esophagus (reflux)
necessary.  Breathing food contents
into the lungs (aspiration),
which can cause
pneumonia
 Tearing (perforation) of
the esophagus

https://medlineplus.gov/ency/article/000267.htm
 Prevention
 Many of the causes of achalasia cannot be prevented.
However, treatment may help to prevent complications.

https://medlineplus.gov/ency/article/000267.htm