A case report of achalasia

Abstract

Achalasia is characterized by esophageal nonperistaltic contraction and incomplete relaxation of the lower esophageal sphincter. The most common symptom are dysphagia, regurgitation, and heartburn. A 48 years old male was admitted into HAM General Hospital Medan with achief complaint of dysphagia since adulthood. The patient had to drink a lot of water to help swallow solid or soft food. Complaint worsened in the last three months followed by odynophagia, nausea, and vomiting undigested, retained food. The patient also complained about heartburn and was previously diagnosed with a variant of angina pectoris but his symptoms didn’t improve with medication. The patient had a history of weight loss but no anorexia, no prior history of corrosive ingestion. The patient was an active smoker. Physical examination revealed no abnormality. Oesophagogram showed dilated distal esophagus with rat tail appearance. Gastroscopy revealed dilatation on the lower third of the esophagus. Computed Tomography revealed dilatation of distal esophagus. Based on the results of the exams, we concluded the diagnosis as achalasia. The patient was treated with calcium channel blocker and proton pump inhibitor. The patient showed clinical improvement after treated and was discharged. The patient was planned for once a month follow up in the outpatient clinic.