Esophageal cardia achalasia is a neuromuscular dysfunctional disease of the esophagus, caused by the loss of normal innervation of the distal 2/3 muscles of the esophagus, mostly primary, but also secondary to esophageal cancer, gastric cancer, Chagas disease and idiopathic pseudo-intestinal obstruction. The decrease of esophageal peristaltic function and the lack of swallowing relaxation of the lower esophageal sphincter (LES) eventually lead to the gradual dilatation of the body of the esophagus, and the main clinical manifestations are dysphagia, chest pain, food reflux, and wasting. (A) Epidemiology This disease is a rare disease, which can occur at any age, but most commonly occurs in children aged 20-40 years. The incidence is similar in men and women, about 1:1.15. (B) Etiology and pathogenesis This disease is a neurogenic disease, and its motor disorder is due to damage to the cholinergic nerves of the esophagus, but the exact cause is unknown, and may be related to viral infection, genetics, and environmental factors, in addition to emotional/psychiatric factors may be a trigger for the development of this disease. （The main symptoms are dysphagia, food reflux and chest pain; followed by weight loss, other symptoms and complications. Dysphagia is the most prominent symptom of the disease, accounting for more than 80% to 95%; it can occur suddenly or intermittently and slowly without being noticed by patients; it is often triggered by emotional stress or intake of irritating food; during the attack, patients often need to drink a lot of water or make Valsalva action (deep inhalation followed by closing the vocal valve, or closing the mouth and blocking the nostrils for deep exhalation action) to help food enter the stomach. As the disease progresses, the esophagus gradually dilates and food reflux occurs in 60% to 90% of patients, often during or within a few minutes after eating, because the food is undigested and does not contain stomach acid, so there is no sour smell, but it can be mixed with a lot of mucus, and the symptoms are relieved when the food is vomited. Sometimes patients may also have nocturnal reflux, complaining of reflux found on the pillow when they wake up in the morning. About 50% of patients have chest pain, located behind the sternum or under the sword, but also in the chest and back, mostly occurring during meals, manifesting as burning pain, dull pain, pins and needles, sometimes resembling angina pectoris, relieved by taking nitroglycerin or eating a hot meal. In severe cases of eating difficulties, weight loss, malnutrition, vitamin deficiency and anemia may occur. 2.Complications include aspiration pneumonia, esophagitis, esophageal diverticulum, and cancer. Among them, aspiration pneumonia is more common, with an incidence of about 10%, and in severe cases, lung abscess, pulmonary atelectasis and pleural effusion occur. The incidence of esophageal cancer complicating this disease is 2%~7%, and the duration of the disease is more than 10 years, especially when there is serious food retention in the esophagus for a long time, regular gastroscopy should be performed. (4) Auxiliary examination 1. X-ray examination (1) Chest X-ray: early chest X-ray has no abnormal findings. In severe cases of esophageal dilatation, mediastinal widening and mediastinal shadow can be seen, and liquid level can be seen in the esophagus. Complicated pulmonary infection can be seen in the corresponding performance. (2) Esophagogram: It is an important test to diagnose this disease. Typically, the esophagus is dilated to varying degrees, lacking peristaltic waves, with a “beak-like” narrowing at the lower end, and slow or obstructed passage of barium. In severe cases, the dilatation of the esophagus can exceed 6 cm. 2. Gastroscopy: In mild cases, there may be no obvious abnormalities. In typical cases, the lumen of the esophagus is widened, food or liquid is retained in the lumen, the cardia is tightly closed, and the endoscope passes with resistance or is unable to pass; the esophageal mucosa is mostly normal, but inflammatory changes such as congestion, erosion or ulceration can also occur. Attention should be paid to exclude the possibility of secondary cardia failure due to cardia malignancy. (3) Esophageal manometry: typical manifestations are (1) elevated LES resting pressure >30 mmHg, poor relaxation during swallowing; (2) reduced peristaltic amplitude and poor conductivity in the body of the esophagus, with obvious performance in the distal esophagus; (3) elevated intraesophageal pressure, exceeding the intragastric pressure. (E) Diagnostic criteria: The disease can be diagnosed with typical manifestations such as dysphagia, food reflux and chest pain, with typical x-ray signs and characteristic manifestations of esophageal manometry. (vii) Treatment 1. Treatment aims and principles: There is no effective method to restore the function of the already damaged esophageal intermuscular plexus, so the treatment aims to relieve the relaxation disorder of the LES, improve the symptoms and prevent complications. 2. General treatment: Avoid emotional stressful events and spicy and stimulating diets, eat less and more often, chew and swallow slowly, and do not lie down within 1 to 2 hours after meals. For patients with severe disease should be fasted as appropriate, intravenous nutritional support therapy. 3.Medication: Only short-term improvement of symptoms, long-term efficacy is poor. It is suitable for patients with mild disease or intolerance/refusal of invasive treatment. Commonly used drugs include (1) nitrates, such as nitroglycerin 0.6mg, Tid; isosorbide nitrite (cardiac pain) 5mg, Tid. (2) calcium antagonists, such as nifedipine (cardiac pain) 10mg, Tid. all of these drugs are taken 15 minutes before meals, pay attention to the side effects of drugs leading to hypotension, headache, etc., the first time the patient is recommended to lie down for at least half an hour. 4, endoscopic treatment: endoscopic dilatation therapy is currently the best non-surgical treatment for cardia achalasia. Indications are patients with severe dysphagia, significant narrowing of the lower esophagus conventional endoscope (mirror diameter of about 1cm) can not pass, and appear to be significantly wasted. Conventional dilators and balloon dilators can be used, with the latter being more effective. Complications include bleeding and perforation. Botulinum toxin binds to receptors on nerve endings and reduces the release of acetylcholine to achieve relaxation of smooth muscle. Endoscopic injection of botulinum toxin into the LES can be used to treat this disease. Endoscopic treatment of cardia incontinentia has good short-term efficacy, but long-term efficacy is not good and can be repeatedly implemented. 5.Surgical treatment: Surgical treatment can be adopted for patients whose appeal treatment is ineffective and whose symptoms are serious or suspected to be cancerous. There are two methods: open and minimally invasive surgery. Transthoracic Heller myotomy is the standard method of open surgery, with an efficiency of 80% to 90%. At present, minimally invasive surgical methods via thoracoscopy or laparoscopy have been adopted at home and abroad, which greatly reduces complications and is expected to become the preferred treatment method for this disease. 6, the latest endoscopic treatment progress – endoscopic esophageal submucosal dissection of the cricoid muscle (peroral endoscopic myotomy, POEM) is a new minimally invasive surgery for the treatment of pancreatic flaccidity, through the endoscopic direct view of the esophageal cricoid muscle in order to achieve the purpose of similar to laparoscopic Heller surgery; at present, our hospital has completed 10 More than 10 cases have been completed in our hospital with very satisfactory results (please refer to the article on POEM treatment by Director Huang Yonghui). The main complications include bleeding, perforation, pneumothorax, anesthesia accident, aspiration pneumonia, etc.