Picture Diagnosis

Q: Patient presents with 10 years of difficulty swallowing food and water. It became worse over the last 3 months. Chest X-ray showed this. What is your diagnosis?

Answer:  The chest X-ray shows a significantly dilated esophagus filled with food and fluid, with an air-fluid level and absence of peristalsis. These findings are highly suggestive of achalasia, a primary esophageal motility disorder characterized by failure of the lower esophageal sphincter (LES) to relax.

Diagnosis: Achalasia

Supporting Features:

• Progressive dysphagia (starting with solids, later affecting liquids)
• Long duration (10 years, worsening over 3 months)
• 
  

Chest X-ray findings:

• Widely dilated esophagus
• Air-fluid level
• Mediastinal widening due to food stasis
• Absence of gastric air bubble (suggesting LES dysfunction)

Next Steps:

1. Confirm with Barium Swallow: "Bird-beak" narrowing at the gastroesophageal junction.

2. Esophageal Manometry: Absent peristalsis, high LES pressure, incomplete relaxation.

3. Endoscopy: Rule out malignancy (pseudoachalasia).

#GI

Further readings:

1. Ribolsi M, Andrisani G, Di Matteo FM, Cicala M. Achalasia, from diagnosis to treatment. Expert Rev Gastroenterol Hepatol. 2023 Jan;17(1):21-30. doi: 10.1080/17474124.2022.2163236. Epub 2023 Jan 1. PMID: 36588469.

2. Cappell MS, Stavropoulos SN, Friedel D. Updated Systematic Review of Achalasia, with a Focus on POEM Therapy. Dig Dis Sci. 2020 Jan;65(1):38-65. doi: 10.1007/s10620-019-05784-3. Epub 2019 Aug 27. PMID: 31451984.