Achalasia in a 40-Year-Old Man

A 40-year-old man presented with a 1-year history of progressively worsening dysphagia. He reported difficulty in swallowing both solids and liquids and had experienced mild weight loss during the past few months. He had no history of gastroesophageal reflux. A chest radiograph showed the absence of a gastric bubble and an air-fluid level in the mediastinum (A). These findings indicated the presence of retained food in the esophagus and were highly suggestive of achalasia. Results of a barium swallow test showed a dilated esophagus, which confirmed the diagnosis. A CT scan of the chest also revealed a dilated esophagus (B). Endoscopic findings ruled out gastroesophageal malignancy. Sonia Arunabh, MD, and Manjula Thopcherla, MD, of Forest Hills, NY, write that achalasia develops when the lower esophageal sphincter does not relax properly with swallowing and results in dysphagia. The underlying cause of this motor disorder may be the loss of neurons in the smooth muscle portion of the esophagus. The typical course is progressive dysphagia and weight loss. In addition to chest radiographs and barium studies, a CT scan of the chest can provide evidence of a dilated esophagus. Esophageal manometry studies can demonstrate specific abnormalities of muscle function that are characteristic of achalasia, such as failure of the lower sphincter to relax. An advantage of manometry is that it can provide diagnostic findings early in the course of disease, a period in which the video-esophagram may appear normal. Achalasia can be managed with a diet of soft food and injection of botulinum toxin type A in the lower esophageal sphincter via endoscopy, which helps relax the sphincter. Oral nitrates and calcium channel blockers can also help relax the lower esophageal sphincter. Although these medications relieve symptoms in some patients with achalasia, they are often not used because of their adverse effects. Balloon dilatation of the esophagus is the initial recommended treatment. In patients with resistant achalasia, surgery-incision of the circular muscle of the lower sphincter-is often effective. This patient was given an injection of botulinum toxin with satisfactory results. Consider achalasia in all patients who have dysphagia. Appropriate treatment can prevent chronic disease, which may predispose patients to esophageal cancer.