Informal Notes of Meeting with Majid Hashemi on 18 December 2014
regarding Achalasia at St John & St Elizabeth Hospital
An informal meeting and question and answer session with the London Achalasia
Meetup Group, which is linked to the Oesophageal Patients’ Association, was held at
the above hospital by Majid Hashemi Mb, ChB, FRCS (Gen), Lead Consultant UGI
Surgeon, Senior Lecturer. The meeting was arranged by Amanda Ladell, of London
Achalasia Meetup Group, and Alan Moss, of the Oesophageal Patients’ Association.
Majid Hashemi has had 26 years in surgery, with 15 years in oesophageal work.
Thanks are due to David Marshall, Chief Executive, for allowing us to hold this
meeting which was very much appreciated by the 27 guests (this includes 7
partners) who attended.
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Oesophagus is approx. 20 cm long and finishes at oesophagus junction with
stomach. It is an active organ, with peristaltic contractions.
Need progressive peristalsis, timing and pressure important
Sphincter needs to function properly
Hiatus needs good angle with oesophagus
Sling of muscles like an arch. Need stomach and small bowel to empty well +
saliva lubricating the passage well.
Manometer good for pressure measurement
1 hr. manometry test, tube from the nose, not a pleasant test but gives a
definitive answer
What is it?
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Non relaxing lower oesophageal sphincter
High resting pressure in lower oesophagus
Poor contraction in the oesophagus
Simultaneous and badly co-ordinated contractions in the oesophagus
Contractions happening simultaneously
Sphincter should relax, lose the inhibition of tone
High resting tone and non-relaxing tone
Low pressure. Simultaneous high pressure and non-relaxing sphincter
Bolus non-clearance because sphincter not opening
After treatments, use gravity for food to go to stomach
Vigorous achalasia – high pressure contractions of 180 mm Hg – ‘nutcracker’
oesophagus. Healthy oesophagus generates 80 – 120 mm Hg
Can get a whole range of pressures
Chaga’s disease mimics achalasia
Pseudo-achalasia can be diagnosed
Chest pains hardest to treat by surgery and tricky to treat afterwards
Multi-factors cause it including tiredness and how fit one is
Myotomy doesn’t stop the spasm
Oesophagitis can be the cause of the spasm
Bananas help a lot
Informal notes of meeting 22.12.14
Ann Elms
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Treatment of the spasms
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Try nitrates
Try calcium channel blockers
Try Buscopan
Gentle pressing downward in the middle area of the chest
Deep breathing
Stretching upwards
Relaxation
Standing on tiptoes and cracking down on heels vigorously – the shock helps
to push the food down
Role of fermentation and reflux causes pain
Sucralfate can help as a temporary stopgap to give pain relief
Try drinking warm water
Try holding a hot water bottle on the chest to give pain relief
Eat a piece of banana
Pathology
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Loss of inhibitory gangli
Viral – measles, varicella zostervirus, Chaga’s
Genetic
Nitric oxide
Auto immune
Research on vagal nerve & sympathetic nerves
Sometimes colon does not have much peristalsis
May have predisposition to cardiomyopathy
Common presentation
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Dysphagia
Regurgitation
Reflux
Pain
Respiratory problems
Laryngeal problems
Can get aspiration pneumonia
Post nasal drip
Nocturnal cough – need to be most concerned about this
Weak voice after 1 hour
Get tired with having to talk loudly
Diagnosis and Investigation
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History
1/3 – ½ do not pick up achalasia, mostly reflux is the cause
endoscopy
Barium swallow
Informal notes of meeting 22.12.14
Ann Elms
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Manometry
“Bird’s beak” shaped oesophagus
Sometimes treatment leads to wide open sphincter and oesophagus can fold
over on top of itself and pooling can occur
If treatment effective, this pooling doesn’t happen
Who does it affect?
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Men and women
1 in 100,000 annually diagnosed
10 in 100,000 prevalence
any age 16-80’s 1st presentation
30-60 years most common
Some genetic predisposition
Treatment
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Two parallel strategies
Avoiding stress and exacerbating factors
Medical
Endoscopic treatment
Surgery
First treatment is the best chance of getting it right
Type 1 – no peristalsis
Type 2 – oesophageal pressurization
Type 3 – vigorous - chest pains
General question and answer session
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Botox has helped with chest pain, has had myotomy and is going to have
POEM. Symptoms bad at night, cough if lying on the right side.
Mostly people have problems if lying on the right.
May have sigmoid oesophagus
A machine for moisturising air helped nocturnal cough
Lying on stomach can help cough but not recommended. Will be less likely to
aspirate but not recommended as a position
If you have aspiration problems, get it checked.
Advise some elevation, upright with pillows is best
? many dilatations – 6 or 7 dilatations are safe
Need to have durable solution and dilatation lasts only about 14 months
Really effective dilatation or myotomy as first treatment is best
Dilatation if too old for surgery. 40 mm dilatation with achalasia balloon is
done first. Do a post dilatation swallow immediately. One achalasia sufferer
had dilatation from age 19, now 42.
Most people who had botox, need further treatments.
Route if fit is to go either for dilatation or surgery. If that doesn’t work, then
one still has the choice of dilatation or surgery
Informal notes of meeting 22.12.14
Ann Elms
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Third time surgery is not very easy with dilatation
If unfit – dilatation or botox is the treatment
Choice is linked to local expertise and patient choice.
If you don’t have a wrap, you may get severe reflux. Fundoplication is wrap to
reduce reflux. Wrap and fundoplication is essential and surgery is
recommended if fit.
Tablets to switch off acid, such as proton pump inhibitors like omeprazole,
can lead to benign polyps and osteoporosis. Best not to be on them for long
term but use them for a while and then stop.
Presence of an ulcer – need endoscopy. Extremely rare to develop squamous
cancer – irritation of oesophagus (much more common 20 years ago).
Stasis and irritation of lower gullet
Duodenal ulcer – not a side effect of achalasia
Gastrin levels, amount of acid – biopsy and keep an eye on it
What is likelihood of wrap loosening over time? Can have the wrap tightened.
Measure the manometry pressure. The Mucosa is stronger if you haven’t had
dilatation. Don’t want too tight a wrap or it might restrict too much.
Some surgeons are pioneering the POEM procedure, but it is not recognized
as standard procedure at the moment. It is more complex, and does not in
itself provide the means for providing a “valve” to prevent reflux. Current
thinking for many surgeons would be to recommend keeping to the safer and
more controlled option of myotomy and a form of wrap for most situations.
Candida
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A brief paper was tabled by a member who has suffered from candida of the
oesophagus and how she dealt with it over the years before achalasia was
finally diagnosed. It is a major contribution to dysphagia. If oesophagus is not
emptying, it will become infected and one can get run down. Conventional
treatment is with Nystatin which can be taken up to 5 times a day, or
fluconazole – these can have side effects.
Get source of candida reviewed
Barium swallow and brushing
After treatment, check if it has gone – swabs from throat? Endoscopy and
brushing?
Try the different tips for a short period. Watch use of probiotic as one can get
over-growth of bacteria in the colon.
Other effects of achalasia
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Can get extreme burping and tiredness
14 people in the room had had treatment, 4 had not had treatment
Two have not had manometry
Anything from oesophagus can be referred to back of throat
All should have follow-up.
80% of people get 80% improvement
If myotomy hasn’t worked, can have dilation
Informal notes of meeting 22.12.14
Ann Elms
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Can have revision myotomy
Should not leave expanded oesophagus. If getting regurgitation will affect
throat.
Most achalasia sufferers eat less than they previously did.
Buttermints can help.
Pineapple juice can help.
Need drinks at room temperature
Mr Hashemi’s team are getting a trained psychologist on benign reflux team.
For the next meeting, Mr Hashemi will aim to have a clinical psychologist and a
dietician present. It is hoped to hold this in the summer.
Informal notes of meeting 22.12.14
Ann Elms
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