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