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Diagnosing Achalasia

Tuesday, July 14, 2009 @ 11:07 AM
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by Pankaj J Pasricha, MD
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Achalasia is usually suspected based upon symptoms, although tests are needed to confirm the diagnosis.

Chest x-rays — A simple chest x-ray may reveal abnormal changes in the esophagus and absence of air in the stomach, two abnormalities that suggest achalasia.

Barium swallow test — The barium swallow test is the primary screening test for achalasia. The test involves swallowing a chalky-tasting, thick mixture of barium while x-rays are taken. The barium shows the outline of the esophagus and LES (lower esophageal sphincter).

Barium swallows are usually performed under fluoroscopy, a continuous low-grade x-ray, which is helpful for studying the motion in the esophagus. In achalasia, barium swallows usually reveals an absence of contractions in the esophagus after swallowing. Sometimes this test shows esophagus contracting spastically in response to swallowing; this variation of achalasia is known as vigorous achalasia.

After the barium swallow, you should drink extra fluid. Stools may be light in color for a few days after testing as a result of the barium.

Manometry — Manometry refers to the measurement of pressure within the esophagus and the LES. Pressures are measured by advancing a thin tube through the mouth or nose into the esophagus. The test is done after having nothing to eat or drink for eight hours, while you are awake. You will be asked to swallow while the tube is in place.

Manometry is always used to confirm achalasia. The test typically reveals three abnormalities in people with achalasia: high pressure in the LES at rest, failure of the LES to relax after swallowing, and an absence of useful (peristaltic) contractions in the lower esophagus. The last two features are the most important and are required to make the diagnosis.

Endoscopy — Endoscopy allows the physician to see the inside of the esophagus, LES, and stomach using a thin, lighted, flexible tube. Endoscopy is done while you are sedated. This test is usually recommended for people with suspected achalasia and is especially useful for detecting other conditions that mimic achalasia. (See "Patient information: Upper endoscopy".)

In people with achalasia, endoscopy often reveals abnormal changes in the esophagus and food that has become stuck; it may also reveal inflammation, small ulcers caused by residual food or pills, and candida (yeast) infection.

The endoscope can be advanced through the LES and into the stomach to check for stomach cancer. Cancer in the upper part of the stomach can produce symptoms almost identical to those of achalasia, and is called pseudoachalasia (meaning "false" achalasia). Thus, biopsies (small samples of tissue) are often obtained in the lower portion of the esophagus. Having a biopsy while sedated is not painful and is saf

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