Achalasia

Diagnosis: Achalasia

Findings on Imaging:

Esophagram shows a dilated esophagus with a narrowed lower esophageal sphincter that fails to relax during swallowing.
Bird-beak narrowing as seen on this barium swallow study.
The absence of air in the expected location of the gastric bubble on frontal radiograph is also seen here.
No evidence of mid-esophageal strictures or masses is seen.
Manometry confirms the diagnosis of achalasia, with incomplete relaxation of the lower esophageal sphincter and absent peristalsis in the distal esophagus.

Next Steps in Management:

Management of achalasia typically involves interventions to improve esophageal emptying and relieve symptoms.
Options for treatment include pharmacologic agents, endoscopic therapies, and surgery.
Pharmacologic agents, such as calcium channel blockers or nitrates, may be used to reduce lower esophageal sphincter pressure and improve esophageal emptying.
Endoscopic therapies, such as pneumatic dilation or botulinum toxin injection, can also be effective in relieving symptoms of achalasia.
Surgery, such as a Heller myotomy, is a more invasive option that may be considered if other treatments are not successful.

Key Take Away Points:

There is often loss of esophageal peristalsis and loss of relaxation of the LES – lower esophageal sphincter. As a result there is an obstructive process resulting in food stasis and marked proximal dilatation of the esophagus. The differential diagnosis is secondary achalasia or pseudochalasia from possible malignancy is also a diagnostic consideration.
Achalasia is a disorder of the esophagus that results in incomplete relaxation of the lower esophageal sphincter and absent peristalsis in the distal esophagus.
Diagnosis is typically confirmed with esophagram and manometry.
Management of achalasia involves interventions to improve esophageal emptying and relieve symptoms, including pharmacologic agents, endoscopic therapies, and surgery.
Early intervention can improve outcomes and prevent complications associated with achalasia.

Credit: Case submitted by Dr. Saeed Rad MD to radRounds Radiology Network