Achalasia

Pathology

Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.

Clinical features

dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food - may lead to cough, aspiration pneumonia etc
malignant change in small number of patients

Investigations

manometry: excessive LOS tone which doesn't relax on swallowing - considered most important diagnostic test
barium swallow shows grossly expanded oesophagus, fluid level, 'bird's beak' appearance
CXR: wide mediastinum, fluid level

Treatment

intra-sphincteric injection of botulinum toxin
Heller cardiomyotomy
balloon dilation
drug therapy has a role but is limited by side-effects


© Image used on license from Radiopaedia

This film demonstrates the classical 'bird's beak' appearance of the lower oesophagus that is seen in achalasia. An air-fluid level is also seen due to a lack of peristalsis


© Image used on license from Radiopaedia

Mediastinal widening secondary to achalasia. An air-fluid level can sometimes be seen on CXR but it is not visible on this film


© Image used on license from Radiopaedia

Barium swallow - grossly dilated filled oesophagus with a tight stricture at the gastroesophageal junction resulting in a 'bird's beak' appearance. Tertiary contractions give rise to a corkscrew appearance of the oesophagus