Achalasia

Full stomach regardless of NPO - Retained food and saliva sit above a sphincter that will not relax, so an NPO order does not clear the esophagus. Treat every achalasia patient as a full stomach.

Aspiration is the headline risk - Aspiration pneumonia accounts for more than half of airway-related anesthesia deaths, and survivors face substantial morbidity and prolonged ICU care.

Preop imaging and manometry - Chest and neck radiographs showing a dilated esophagus with an air-fluid level flag a retained bolus. High-resolution manometry grades it: an elevated integrated relaxation pressure with failed peristalsis defines achalasia, and type III adds spastic distal contractions.

Holding-area exam beats the fasting clock - A patient sitting up, leaning forward, and spitting saliva into an emesis basin is still impacted no matter how long they have been NPO. That single finding is enough to change the plan.

Push back on MAC for EGD - The GI team will often request sedation. Propofol strips protective airway reflexes, and general anesthesia with an ETT after RSI is the safer plan even when the aspiration risk looks small.

Preparation before induction - An H2 receptor antagonist to lower gastric acidity, a prokinetic to reduce gastric contents, an NG tube to decompress the food bolus, strong suction at the head of the bed, and enough hands to turn the patient left lateral fast.

Induction - RSI with a video laryngoscope for the quickest possible intubation. Cricoid pressure is not protective here; in a reported case a pool of saliva and food particles appeared in the posterior oropharynx despite it. Have a Yankauer in your hand as the blade goes in.

Extubation is the second danger point - Up to 20% of aspiration events happen after extubation. Extubate fully awake and in the left lateral position with the dependent corner of the mouth low, so retained esophageal contents drain out rather than down the trachea.

Know the procedure you are covering - Pneumatic dilation carries about a 2% perforation risk. Heller myotomy is paired with a fundoplication; peroral endoscopic myotomy (POEM) is not, so reflux is common afterward. Botulinum toxin into the LES is reserved for patients who are poor candidates for the rest.

Anxiety and nutrition - These patients arrive anxious after a long, uncomfortable course of dilations, NG tubes, and repeat endoscopies, and months of poor intake leave many volume depleted and malnourished.

Achalasia is an esophageal motility disorder caused by degeneration of ganglion cells in the myenteric plexus. The inhibitory nonadrenergic, noncholinergic neurons that release vasoactive intestinal peptide (VIP) and nitric oxide are lost while the excitatory cholinergic neurons are spared, so the lower esophageal sphincter (LES) never relaxes with a swallow and the distal esophageal body loses peristalsis. The result is a functional obstruction at the gastroesophageal junction, progressive dilation above it, and eventually irreversible aperistalsis.

Prevalence is roughly 10 per 100,000, and most patients are diagnosed between 25 and 60 years of age. Dysphagia to solids (91%) and liquids (85%) with regurgitation of undigested food and saliva (up to 91%) are the usual complaints. The perioperative consequence is simple: a column of retained food and saliva sits above a sphincter that will not open, and fasting does not empty it.