FFinalistSouthampton · 2027
Gastroenterology
AKT · Gastroenterology/Oesophagus & stomachlow yield

Achalasia

Failure of LOS relaxation + loss of oesophageal peristalsis (degeneration of myenteric plexus)

Overview

A primary motility disorder — failure of the lower oesophageal sphincter to relax with loss of distal peristalsis, from degeneration of the myenteric (Auerbach) plexus. Causes dysphagia to BOTH solids and liquids from the outset, regurgitation and weight loss. Barium shows a dilated oesophagus tapering to a 'bird-beak'; manometry confirms. Long-standing achalasia raises squamous-cancer risk. (Chagas disease is the secondary/infective cause.)

Recognise

  • Dysphagia to SOLIDS AND LIQUIDS from the start (vs the solids-first progression of cancer/stricture)
  • Regurgitation of undigested food, nocturnal cough/aspiration, weight loss, chest pain
  • Barium: dilated oesophagus with smooth tapering 'bird-beak' narrowing; manometry: absent peristalsis + non-relaxing LOS; small risk of SCC

Red flags

  • Older patient with rapid weight loss and short history → exclude PSEUDOACHALASIA (tumour at the GOJ) with endoscopy
  • Aspiration pneumonia

Differentials & how to tell them apart

Oesophageal cancer / peptic stricturedysphagia for SOLIDS first; mechanical stricture, not a motility pattern
Pseudoachalasia (GOJ tumour)older, rapid weight loss, short history — endoscopy/imaging to exclude a cancer mimicking achalasia
Diffuse oesophageal spasmintermittent chest pain/dysphagia, 'corkscrew' oesophagus
Eosinophilic oesophagitisyoung atopic, food impaction, eosinophils on biopsy
Achalasia — dilated oesophagus tapering to a smooth 'bird-beak' (contrast swallow)

Achalasia — dilated oesophagus tapering to a smooth 'bird-beak' (contrast swallow)

brewbooks / CC BY-SA 2.0 — Wikimedia Commons

Investigations

Oesophageal MANOMETRY (diagnostic — aperistalsis + failure of LOS relaxation); barium swallow (bird-beak); ENDOSCOPY to exclude malignancy (pseudoachalasia).

Management

Pneumatic dilatation or Heller myotomy/POEM (botulinum toxin if unfit)

  1. 1Confirm with manometry; barium (bird-beak); endoscopy to exclude a tumour. Definitive treatment is pneumatic dilatation or surgical myotomy (Heller/POEM).Gate: Always endoscope to exclude PSEUDOACHALASIA (a GOJ tumour mimicking achalasia), especially in older patients with rapid weight loss and a short history
  2. 2Botulinum toxin for the unfit; surveillance for the small SCC risk; manage reflux post-myotomy.
Pneumatic balloon dilatation or Heller myotomy / POEM — definitive — disrupt the LOS
Botulinum toxin injection — for those unfit for definitive treatment (temporary)
Nitrates/calcium-channel blockers — limited symptomatic relief

Key points

Dysphagia to solids AND liquids from the outset + bird-beak barium + aperistalsis on manometry = achalasia. The trap is pseudoachalasia (a GOJ cancer) — always scope.

Monitor & prognosis

Symptoms; SCC surveillance; post-treatment reflux.

Good symptom control with treatment.

Source: BSG; StatPearls