Esophagus – cardia achalasia: also known as cardia spasm and megaesophagus, is a disease caused by esophageal neuromuscular dysfunction, which is mainly characterized by lack of peristalsis, high pressure of the lower esophageal sphincter (LES) and a reduced relaxation response to swallowing movements. Clinical manifestations include dysphagia, food reflux and lower retrosternal discomfort or pain. It is a rare disease (estimated at only about 1 in 100,000 people) and can occur at any age, but is most common in the 20-39 year old age group. The disease is rare in children and is more common in men and women with approximately equal incidence. The disease is mostly seen in young adults. The main pathological change is the reduction or even disappearance of the number of ganglion cells in the interstitial plexus of the esophageal wall, which can involve the entire thoracic segment of the esophagus, with the lower and middle part of the esophagus being the most obvious. Main clinical manifestations (a) dysphagia: painless dysphagia is the most common and earliest symptom of the disease, accounting for more than 80% to 95%. The onset of the disease is slow, but it can also be urgent, and it can be mild at first, with a feeling of fullness after meals. Dysphagia is mostly intermittent, often triggered by mood swings, anger, apprehension, shock or irritating food such as too cold and spicy. At the beginning of the disease, dysphagia is intermittent, sometimes mild and sometimes severe, but later it becomes persistent. A few patients have more difficulty swallowing liquids than solid foods, and this sign has been used to distinguish dysphagia from other organic esophageal strictures. However, most patients have more difficulty swallowing solids than liquids, or have equal difficulty swallowing solid and liquid food. (b) Pain: about 40% to 90% of the patients have pain of varying nature, which can be boring, burning, pinching, cutting or cone pain. The pain site is mostly in the posterior sternum and the middle and upper abdomen; it can also be in the back of the chest, the right side of the chest, the right sternal margin and the left quarter rib area. The pain attacks sometimes resemble angina pectoris and may even be relieved by sublingual nitroglycerin tablets. The mechanism of pain can be due to strong contraction of the smooth muscle of the esophagus or to food retention esophagitis. With the gradual increase of dysphagia and further dilatation of the esophagus above the obstruction, the pain can be gradually reduced. (iii) Food reflux: the incidence can be up to 90%, with the aggravation of dysphagia and further dilatation of the esophagus, a considerable amount of contents can be retained in the esophagus for several hours or days, and reflux out when the position changes. The contents of reflux from the esophagus do not have the characteristics of vomit in the stomach because they have not entered the gastric cavity, but they can be mixed with large amounts of mucus and saliva. In case of complications of esophagitis and esophageal ulcer, the reflux may contain blood. (iv) Weight loss: Weight loss is associated with dysphagia affecting the intake of food. For dysphagia, although patients mostly adopt methods such as choosing food, eating slowly, rinsing food down with more soup during or after eating, or straightening the chest and back after eating, breathing hard and deeply or rejecting air to assist the swallowing action, so that food can enter the stomach and ensure nutritional intake. The amount of long-lasting disease can still have weight loss, malnutrition and vitamin deficiency and other manifestations, while the cachexia is rare. (E) Bleeding and anemia: Patients can often have anemia and occasionally bleeding due to esophagitis. (vi) Other symptoms: Due to the increased tone of the lower esophageal sphincter, patients rarely experience eructation, which is an important feature of the disease. In late cases, the extremely dilated esophagus may compress the organs in the chest cavity and produce dry cough, shortness of breath, cyanosis and hoarseness. Auxiliary diagnostic tests 1. Upper gastrointestinal imaging: Barium meal is often difficult to pass through the cardia and is trapped in the lower end of the esophagus, and shows a funnel-shaped stricture of 1 to 3 cm long, symmetrical, mucosal pattern parties, and the upper part of the esophagus shows different degrees of dilatation, length and curvature, without peristaltic waves. Barium meal x-ray of the esophagus shows barium retained in the cardia, and the lower part of the esophagus shows a bird’s mouth narrowing with smooth edges, and the barium enters the stomach slowly in a fine stream. 2.Gastroscopy: Gastroscopy shows different degrees of esophageal dilatation, delayed or no relaxation of the cardia, and the mirror body is difficult to pass. 3.High-resolution esophageal manometry: This test is more advanced and has higher specificity for diagnosing achalasia of the cardia. After the patient is instructed to swallow water, the cardia opening is not relaxed or the relaxation rate is reduced as seen on the pressure map, there is no coordinated peristaltic wave in the body of the esophagus, and the lumen of the esophagus can be diffusely high-pressure. Treatment 1, change the diet: it is advisable to eat less and chew more, avoid too cold, too hot and stimulating diet. Psychological treatment can be given for mental nervousness. Sublingual nitroglycerin can release the spasmodic pain of esophagus and temporarily relieve the discomfort. 2.Balloon dilation: Apply balloon or probe to dilate the esophagus to relax the connection with the stomach. Under fluoroscopy, a balloon is inserted through the mouth with the probe as the anterior guide, so that the probe enters the mouth of the stomach, and the balloon is fixed at the connection between the esophagus and the stomach and injected with air or liquid, and the injection of air or liquid is stopped when chest pain appears. It is left in place for 5 to 10 minutes and then withdrawn. After 5 years of follow-up after one treatment, the effective rate reached 60% to 80%. The effective criterion is that the difficulty due to the lower disappears and normal diet can be resumed. However, this treatment has a high incidence of esophageal perforation and should be operated with caution. 3.Surgical treatment: laparoscopic Heller sphincterotomy, laparoscopic myotomy of cardia esophagus will be performed to cut the circular muscle of lower esophagus and gastroesophageal junction to release the obstruction around cardia, which has the characteristics of small trauma and safe and effective. The rate of symptomatic improvement of surgical treatment is about 80%, but rupture of esophageal mucosa may occur. If fundoplication is performed at the same time, the possibility of reflux is greatly reduced. 4, endoscopic botulinum toxin injection therapy: esophagoscopic local injection of botulinum toxin, through the toxin to block the release of presynaptic acetylcholine at the neuromuscular junction of the cardia sphincter muscle to relax the muscle to relieve symptoms. The advantages of this injection are easy operation, good tolerability, low treatment cost, few adverse effects, and recent efficacy close to that of balloon dilation, but the effect is not long-lasting, easy to recur, and requires repeated injections, which is suitable for elderly patients and patients with multiple diseases who cannot tolerate surgery or balloon dilation, and those with poor efficacy of surgery or multiple balloon dilation.