ACHALASIA

It is the most common motor disorder of the esophagus. It affects both sexes equally. In patients with achalasia, ganglion cells are absent in the Aurbach myenteric plexus in the distal esophagus.

In addition to idiopathic achalasia, it may also develop due to autoimmune destruction caused by HSV type 1.

Myenteric antiplexus antibodies can be shown in 100% of men and 67% of women.

Causes of secondary achalasia include amyloidosis, chronic idiopathic intestinal pseudoobstruction, eosinophilic esophagitis, Fabry disease, juvenile Sjögren's syndrome, multiple endocrine neoplasia type 2b and neurofibromatosis.

Almost all of the patients have dysphagia against solid foods, while 66-85% have dysphagia against liquid foods.

Patients initially feel a feeling of heaviness or tightness in the chest with stress. Retrosternal pain may occur in 40-60% of patients. Over time, they become afraid of eating. Regurgitation of undigested food occurs in 60-90% of patients. Difficulty in burping is present in 85% of patients.

Pneumonia can be seen in elderly patients (8%).

Symptoms do not correlate with the radiological situation.

Epiphrenic diverticula are often associated with achalasia.

The bird's beak image is classic in the barium examination. Fluoroscopy is also helpful in diagnosis. Esophagograms can be normal in 33% of patients, they are not considered sensitive.

The main diagnostic method is manometric examinations. HRM (high resolution manometry) has become the standard diagnostic tool as it can more specifically characterize motility disorders with EPT findings. Three types of achalasia are determined according to HRM findings.

Esophagoscopy is done to exclude malignancy.

Sublingual nifedipine 10/30 mg, isosorbide dinitrate 5 mg and nitroglycerine 0.4 mg can be used as drug therapy; They are taken 30, 15 and 15 minutes before meals, respectively. These drugs are used to lower the LES pressure before meals. Oral calcium channel blockers have also been shown to be useful.

Botulinum toxin can benefit 30-75% patients and can be preferred in elderly and debilitated patients who are not suitable for more invasive procedures.

Although balloon dilation can achieve success in the improvement of symptoms up to 55-70% in the first dilatation and 93% in multiple applications, it is associated with a perforation risk in 3% of patients. Thoracotomy may be required in half of these perforations.

Laparoscopic Heller myotomy is the preferred method in surgical treatment. GER is seen in 64% if an anti-reflux procedure (partial fundoplication: Touoet or Dor) is not performed; When applied, this rate decreases to 27%. The probability of developing esophageal cancer in the postoperative period is 2%.

Reports for peroral endoscopic myotomy are not yet sufficient, but good results have been reported in type 3-end stage achalasia.

ALCOHOLIC CARDIOMYOPATHY

Although the incidence in alcoholic women and men is similar, it is almost 9 times higher in overall weight in men. It is most common in 45-59 years old.

Women develop alcoholic CMP at a lower total ethanol dose.

Left vetricular dysfunction correlates with lifetime alcohol intake.

The relationship of alcohol with heart failure follows the “J-curve. In other words, a person who takes 7 glasses of ethanol per week (14 grams of ethanol per day) actually seems to experience some reduction in heart failure risk.

Many people who have developed alcoholic CMP are those who have consumed more than 80-90 grams of alcohol per day for more than 5 years. There are studies that say 15 years on average.

Alcohol intoxication can also cause acute asymptomatic heart failure in healthy individuals.

It is in rough correlation with liver cirrhosis.

Pathogenesis is not fully understood. Acetaldehyde is thought to cause myocardial depression. There is no clarity on many other possible mechanisms.

Pathological findings and clinical findings resemble heart failure due to other etiologies.

Alcoholic CMP is diagnosed by the presence of two of the following three criteria:

• Long-term heavy alcohol use (alcohol consumption> 80 grams per day for at least 5 years)
• Symptoms of CMP (Left ventricular dilatation with low left ventricular ejection fraction),
• Absence of other causes of dilated CMP (HT, valve disease, ischemic causes, etc.)

Treatment of the patient's nutritional deficiencies such as vitamin B12, B6 and folate; Electrolyte imbalances such as hypokalemia and hypomagnesemia need to be corrected. 

A multidisciplinary approach is required for comorbid conditions such as depression, liver disease, etc. Alcohol should be stopped or if this is not achieved, it should be reduced in cases. 

Even in the short term, left ventricular function has been shown to be better when alcohol is withdrawn. There is no specific marker that can indicate improvement.