Achalasia

Features of Achalasia on Radiographic Studies
1.) Markedly Dilated Esophagus
2.) Air-fluid level in esophagus on upright view
3.) Tertiary non-stripping peristalsis or aperistalsis
4.) Narrowed “bird-beak” appearance at LES
5.) Absent gastric air bubble

Achalasia on Plain Film:

Widening of mediastinum due to dilated esophagus
Absence of gastric air bubble due to failure of LES relaxation.


Upright Barium Swallow:

Dilated Esophagus filled with air and a bit of barium.
No evidence of peristalsis at fluoroscopy.


Pooling at LES w/ food bolus evident.
Tight LES with “bird beak” appearance

Supine Barium Swallow:
Air-filled, dilated esophagus

Note dilated esophagus.
Note constricted LES.

LES represents a “bird’s beak” appearance.
Small tertiary waves present.

Achalasia with significant tertiary peristalsis is termed “vigorous achalasia”.


Treatment
1. Medical Therapy – Nitrates and Calcium channel blockers (e.g. nifedipine). No treatment reliably restores function of esophagus.
2. Pneumatic Balloon Dilation of LES – weakens LES by tearing muscle fibers; risk of perforation
• 50% require further treatment within 5 years of dilation
• Risk of perforation ~ 5%
3. Surgical Myotomy (Heller, Laparoscopic) – weakens LES by cutting muscle fibers; thoracotomy necessary if not laparascopic
• 70-85% success at 10 yrs for modified Heller
4. Botulinum Toxin – Relatively new. Endoscopic injection of toxin into LES.
• Short term success. Limited evidence of long term efficacy.
Achalasia patients have 16x risk for esophageal carcinoma – risk is not eliminated by therapy.


Bibliography
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