his is a rare motility disorder in which the lower esophageal sphincter does not relax properly with swallowing. There is also nonperistaltic contraction activity of the esophageal muscularis to cause symptoms (Kahrilas, 2015; Khudyak, 2006). The defect is caused by inflammatory destruction of the myenteric (Auerbach) plexus within smooth muscle of the lower esophagus and its sphincter. Postganglionic cholinergic neurons are unafected, thus, sphincter stimulation is unopposed. Symptoms are dysphagia, chest pain, and regurgitation. Barium swallow radiography demonstrates bird beak or ace of spades narrowing at the distal esophagus. Endoscopy is performed to exclude gastric carcinoma, and manometry is confirmatory. If dilatation of the esophagus and medical therapy does not provide relief, myotomy is considered (Torquati, 2006).
During pregnancy, normal relaxation of the lower esophageal sphincter in women with achalasia theoretically should not occur. Even so, in most women, pregnancy does not seem to worsen achalasia. One report of 20 afected pregnant women found no excessive relux esophagitis (Mayberry, 1987). Khudyak and coworkers (2006) reviewed 35 cases and described most women as symptom free, although esophageal dilatation was needed in a few. A maternal death was reported at 24 weeks' gestation associated with perforation of a 14-cm diameter megaesophagus (Fassina, 1995).
Management of achalasia includes soft diet and anticholinergic drugs. With persistent symptoms, other options include nitrates, calcium-channel antagonists, and botulinum toxin A injected locally (Hooft, 2015; Kahrilas, 2015). Balloon dila tation of the sphincter may be necessary, and 85 percent of nonpregnant patients respond to this. Satin (1a992) and Fiest (1993) and their associates reported successful use of pneu matic dilatation in pregnancy. One caveat is that esophageal peroration is a serious complication of dilatation. Spiliopoulos and colleagues (2013) described a 29-week pregnant woman with achalasia treated for 10 weeks with parenteral nutrition. Surgical correction was performed postpartum.