40 / 242
40
Chapter 4
DIAGNOSTIC
The typical symptoms of patients with achalasia are dysphagia, retrosternal pain, and pyrosis
(Table 1). On average two years after symptoms from oesophageal dysphagia, 40% of these
patients develop respiratory complaints due to (micro) aspiration.
1,2
If a patient shows symptoms that may fit to achalasia, it is important to exclude more
common disorders like gastro-oesophageal reflux, mechanical obstruction bymalignancy of
the oesophagus or surrounding tissues, strictures, foreign bodies, eosinophilic oesophagitis,
or systemic neuromuscular diseases.
The key test for establishing the diagnosis achalasia is oesophageal manometry. During
manometry a thin probe with pressure sensors is inserted through the nose and placed in
the oesophagus while the patient is asked to swallow several times. Results are graphically
displayed on a “map” which indicates the pressure in different locations at different points
in time (Figure 1). In addition to the manometry, barium swallow is performed. Patients have
to swallow barium contrast solution at different times (usually after 0, 1, 2, and 5 minutes).
In achalasia, normal oesophageal motility is absent. The oesophagus above the narrowing
of the LOS is often dilated showing a typical “bird’s beak”- or corkscrew pattern (Figure 2).
The same signs can be observed during oesophago-gastroscopy: oesophageal dilatation,
abnormal ‘twists’, and stasis of food. It could be difficult or impossible to pass the gastro-
oesophageal junction due to hypertonia of the LOS. Another typical finding is a pattern of
candidiasis as a result of stasis of food.
On the basis of manometry results, achalasia can be divided into three subtypes (Figure 3).
Type I indicates an impaired relaxation of the LOS with lack of peristalsis, but with a normal
oesophageal pressure. Type II is characterised by an increased oesophageal pressure. In
type III, additionally spastic contractions of the distal oesophagus are observed. Achalasia
Type II has the best prognosis after treatment, while type III has the worst.
1
Table 1.
Symptoms of achalasia
Symptoms
% of patients
Dysphagia
90%
Pyrosis
75%
Regurgitation or vomiting
45%
Retrosternal pain
20%
Upper abdominal pain
15%
Pain during swallowing
<5%
Cough
20-40%
Chronic aspiration
20-30%
Hoarseness or sore throat
33%
Unwanted weight loss
10%