Chest x-ray shows absence of gastric air bubble. Barium swallow shows dilated esophagus with distal beaklike narrowing and air-fluid level. Endoscopy is done to rule out cancer, particularly in persons >50 years. Manometry shows normal or elevated LES pressure, decreased LES relaxation, absent peristalsis.
Treatment: Achalasia Pneumatic balloon dilatation is effective in 85%, with 3-5% risk of perforation or bleeding. Injection of botulinum toxin at endoscopy to relax LES is safe and effective in two-thirds of patients, but effects last 6-12 months. Myotomy of LES (Heller procedure) is effective, but 10-30% of pts develop gastroesophageal reflux. Nifedipine, 10-20 mg, or isosorbide dinitrate, 5-10 mg SL ac, may avert need for dilation or surgery. Sildenafil may also augment swallow-induced relaxation of the LES. |
Section 3. Common Patient Presentations