TRUE/FALSE statements about achalasia cardia among following is/are: 1. Dysphagia is a presenting problem 2. The cause is absence of Auerbach's plexus 3. Esophagectomy is the treatment 4. Motility improving agents are used in the treatment 5. Barium swallow shows irregular filling defect in lower esophagus

Achalasia cardia is motor disorder of the esophageal smooth muscle in which the LES does not relax normally with swallowing, and esophageal body undergoes nonspecific contractions. (peristalsis is absent or reduced). The pathogenesis of achalasia is poorly understood. It involves: Neurologic degeneration either idiopathic or due to infection. The degenerative changes are either intrinsic (degeneration of ganglion cells of auerbach's myenteric plexus) or extrinsic (extraesophageal vagus nerve or the dorsal motor nucleus of vagus nerve) Pharmacological studies suggest dysfunction of inhibitory neurons containing nitric oxide and vasoactive intestinal polypeptide in the distal esophagus. The cholinergic innervation of the LES is intact or affected only in advance disease. As a result of the abnormality, the LES fails to relax, primary peristalsis is absent in esophagus which dilates. As the disease progresses the esophagus becomes massively dilated and touous. Clinical Presentation: Both sexes are equally affected. It may develop at any age but peak years are from 30 to 60 years of age. Classical clinical symptom is progressive dysphagia for both solids and liquids. Dysphagia is worsened by emotional stress and hurried eating. Diagnosis: Chest X-ray shows absence of gastric air bubbles, an air fluid level in the mediastinum in the upright position representing retained food in the esophagus. Barium swallow shows a dilated esophagus with tapering narrowing in the terminal end of esophagus, described as 'BIRD BEAK' appearance. Fluoroscopy shows loss of normal peristalsis in the lower third of the esophagus. Treatment includes heller's cardiomyotomy, forceful dilation by pneumatic balloon, repeated injection botulinum toxins and drugs improving motility of esophagus. Esophagectomy is not a treatment modality for achalasia cardia. Irregular filling defect is a feature of carcinoma esophagus not of achalasia cardia. Ref: CSDT 13/e, Page 428 ; Schwaz 9/e, Page 850 ; Maingot's 10/e, Page 846 ; Manipal manual of Surgery by K. Raj Gopal Shenoy 2/e, Page 312-14