A Young Man With a New Diagnosis of Achalasia

Abstract

d Clinical Scenario A 32-year-old man began to experience food sticking ntermittently in the midchest about 2 years ago. By the time he resents to the gastroenterology clinic, he is complaining of ysphagia at every meal for most hard, solid foods (ie, bread, eats, uncooked vegetables), and for the past 4 months he has oted dysphagia for liquids, especially cold beverages. Once or wice a week, after his large evening meal, he experiences reguritation of recently eaten food with a nonacidic taste. His wife omplains he “gurgles” at night and sometimes awakes her with oughing. He denies chest pain, but does complain of “hearturn,” improving with over-the-counter Prilosec (Proctor & amble, Cincinnati, OH). His weight is down 10 lb. The complaints of dysphagia for both solids and liquids aise the suspicion of achalasia. A barium esophagram shows a ildly dilated esophagus with a column of barium maintained ust below the clavicles with no emptying in the upright posiion over a 5-minute period. The distal esophagus has narowed, with a small amount of barium intermittently streaming nto the stomach. No orderly peristalsis is seen on fluoroscopy. sophageal manometry confirms the diagnosis, finding a high ower esophageal sphincter (LES) pressure (56 mm Hg) with ncomplete relaxation and low-amplitude, simultaneous mirror mage waves after all swallows of water. The patient and his wife return to your office after completng his tests. They have read extensively about achalasia on the nternet. They have many questions: Will I ever be able to eat ormally? Can you cure this disease? What is the best treatent—pneumatic dilation, surgical myotomy, or botulinum oxin injections? What are the side effects and which one will ive me the most relief for a long time?