Clinical History
Patient with dysphagia and regurgitation
Imaging Findings
A 65 years old patient was referred to our hospital complaining severe dysphagia with food regurgitation since 6 months. The woman underwent endoscopic examination: a gross dilatation of the
esophageal lumen was evidenced in addiction to lumen narrowing in correspondence of the lower esophageal sphincter. Barium fluoroscopy confirmed the endoscopic findings showing poor clearence of the
contrast medium and tertiary contraction waves typical of achalasia; however, to exclude the suspect of extrinsic compression of the lower esophageal sphincter (pseudoachalasia) was requested MRI
examination. Functional magnetic resonance was performed using HASTE T2-weighted and Dynamic Turbo-FLASH T1-weighted sequences after administration of oral contrast agent (Gd-DTPA + yoghurt). MRI
findings excluded the presence of extrinsic compression in the correspondence of lower esophageal sphincter; on the other hand the characteristics of esophageal motility were compatible with those of
barium fluoroscopy confirming the diagnosis of achalasia.
Discussion
Achalasia is an esophageal motor disorder characterized by increased lower esophageal sphincter (LES) pressure, diminished-to-absent peristalsis in the distal portion of the esophagus composed of
smooth muscle, and lack of a coordinated LES relaxation in response to swallowing. Primary achalasia is the most common subtype and is associated with loss of ganglion cells in the esophageal
myenteric plexus. These important inhibitory neurons induce LES relaxation and coordinate proximal-to-distal peristaltic contraction of the esophagus. Secondary achalasia or pseudoachalasia is
relatively uncommon. This condition exists when a process other than intrinsic disease of the esophageal myenteric plexus is the etiology. Examples of maladies causing secondary achalasia include
certain malignancies, diabetes mellitus, and Chagas disease. Dysphagia is the most common presenting symptom in patients with achalasia. The ingestion of either solids or liquids can result in
dysphagia, though dysphagia for solids is more common. The natural history varies. Some patients notice that the dysphagia reaches a certain point of severity and then stops progressing. In others,
the dysphagia continues to worsen, resulting in decreased oral intake, malnutrition, and inanition. Therefore, weight loss is included in the complex of signs and symptoms associated with achalasia,
and it is usually a sign of advanced esophageal disease. The radiologic examination of choice in the diagnosis of achalasia is a barium swallow study performed under fluoroscopic guidance; in the
last years functional MRI became a further interesting option to evaluate esophageal motility and morphology.
Differential Diagnosis List
