This is a barium swallow showing the typical "bird-beak" appearances of achalasia. It usually presents as dysphagia. Endoscopy is usually performed together with oesophageal manometry. A range of treatments are available including simple dilatation and cardiomyotomy (see below).
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What type of xray is this ; what are the findings and what is the diagnosis?
How does this condition usually present ?
What other investigations would you do?
How would you manage this condition?
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(See below for further details)
This is a barium swallow showing the entire length of the oesophagus with extreme narrowing of the oesophago-gastric junction;
There is dilatation, tortuosity, S-shaped bend in the lower oesophagus (sigmoid oesophagus). There is a smooth narrowing at the lower end of the oesophagus referred to as "bird-beak" appearance.
The above appearance is very typical of achalasia of the cardia or cardiospasm.
The condition affects young and middle-aged adults. The onset is insidious with progressive dysphagia. Typically the dysphagia is for liquids rather than solids initially as the solids go down due to their weight. Later the dysphagia is for both. There is a history of regurgitation of food several hours after a meal. The patients may therefore present with retro-sternal discomfort, foetid breath
and aspiration pneumonia which presents as repeated attacks of chest infection.On examination there is very little to find except for pallor and evidence of weight loss. Systemic examination would reveal aspiration pneumonitis.
The diagnosis is confirmed by OGD. When the scope is passed, it feels as though it is entering a gaping cave with dirty fluid and residual food material which moves on respiration. The cardiac orifice is identified with difficulty and is eccentric in position. The fluid is aspirated and biopsy taken which would confirm absence of ganglion cells. At the same time oesophageal balloon
dilatation can be carried out although in severe cases this is unlikely to be successful.
Oesophageal manometry is sometimes carried out although not essential. It would show increased peristalsis in the upper part and a tight lower oesophageal sphincter (LOS).
Non-operative - injection of Botulinum toxin into the lower oesophageal sphincter endoscopically is a new form of treatment although not yet well established. It acts by interfering with the cholinergic neural activity at the LOS.
Balloon dilatation of the LOS - this has the complication of perforation.
Operative - This is Heller's cardiomyotomy. The German surgeon Ernest Heller, first performed the operation on 14th April 1913 when he did a laparotomy and double myotomy. Zaoijer, a Dutch surgeon, showed in 1923 that a single myotomy is adequate and ever since the procedure that has been carried out is strictly speaking a modified Heller's operation.
The procedure can be carried out by laparotomy through an upper midline incision. A complication of his procedure is gastro-oesophageal reflux (GOR) and therefore some surgeons perform an anti-reflux operation at the same time.
The operation can also be done by a thoracic approach through the left lower chest. The myotomy is lateral and therefore there is less chance of damage to the anterior vagus nerve. Moreover, reflux is less common because the myotomy does not extend as far down as in the abdominal approach.
Nowadays the ideal approach is by the laparoscopic or the thoracoscopic route.