Achalasia in PEG Tube Patients: Understanding the Question
The question appears to conflate two distinct conditions: achalasia (a primary esophageal motility disorder) does not occur because of PEG tube placement, as PEG tubes are placed in the stomach and achalasia is an esophageal disease affecting the lower esophageal sphincter. However, I will address both the actual causes of achalasia and PEG-related complications that may mimic dysphagia or feeding difficulties.
True Achalasia: Primary Causes
If the question concerns actual achalasia in a patient who happens to have a PEG tube:
Pathophysiology of Idiopathic Achalasia
- Achalasia results from inflammatory destruction of inhibitory nitrinergic neurons in the esophageal myenteric plexus, leading to failure of lower esophageal sphincter (LES) relaxation and absent peristalsis 1
- The current understanding suggests an initial insult (possibly viral infection or environmental factor) triggers myenteric plexus inflammation, followed by autoimmune response in genetically susceptible individuals, ultimately destroying inhibitory ganglion cells 1
Secondary Causes Mimicking Achalasia
- Pseudoachalasia from malignancy (gastroesophageal junction tumors or infiltrative disease) must be excluded, particularly in older patients with rapid symptom onset 2
- Esophageal wall stiffness from infiltrative diseases, eosinophilic esophagitis, or vascular obstruction can cause EGJ outflow obstruction 2
- Prior anti-reflux or bariatric surgery can produce manometric findings similar to achalasia 2
- Opiate use is a recognized cause of EGJ outflow obstruction that can mimic achalasia 2
PEG Tube-Related Complications (Not Achalasia)
If the question concerns feeding difficulties in PEG patients:
Mechanical Complications
- Tube blockage from inadequate flushing, particularly with hyperosmolar drugs, crushed tablets, potassium, iron supplements, or sucralfate 2
- Gastric mucosal overgrowth can occlude gastrostomy tubes (unlike nasogastric tubes) 2
- Buried bumper syndrome presents with peritubal leakage, immobile tube, abdominal pain, and resistance with formula infusion 3
Gastroesophageal Reflux and Aspiration
- Gastro-oesophageal reflux occurs frequently with enteral tube feeding, affecting up to 30% of patients with tracheostomies and 12.5% of neurological patients 2
- Aspiration may occur silently without obvious vomiting or coughing, leading to pneumonia 2
- Delayed gastric emptying causes nausea (10-20% of patients), abdominal bloating, and cramps 2
Gastrointestinal Symptoms
- ETF-related diarrhea occurs in up to 30% of patients on medical/surgical wards and >60% in ICU patients 2
- Gastric residue accumulation (>200 mL at 4 hours) indicates need for regimen review 2
Diagnostic Approach
For Suspected True Achalasia
- High-resolution esophageal manometry is the gold standard, showing absent peristalsis and elevated integrated relaxation pressure with incomplete LES relaxation 4, 5, 6
- Endoscopy must exclude structural causes including malignancy (pseudoachalasia) 2, 5
- Endoscopic ultrasound or CT imaging of the EGJ is essential when EGJ outflow obstruction is found to rule out secondary causes 2
- Timed barium esophagram provides complementary functional assessment 2, 5
For PEG Complications
- Contrast study with patient prone confirms buried bumper syndrome, as contrast may falsely appear to pass through when supine 3
- Endoscopic visualization is critical for accurate diagnosis of tube-related complications 3
Critical Pitfall
Do not confuse PEG tube feeding difficulties with achalasia—they are anatomically and pathophysiologically distinct. PEG tubes bypass the esophagus entirely, entering directly into the stomach. Any true achalasia in a PEG patient would be coincidental, not causally related to the gastrostomy 7.