Diagnosis of primary versus secondary achalasia: reassessment of clinical and radiographic criteria.

Abstract

Our purpose was to reassess the usefulness of barium studies and various clinical parameters for differentiating primary from secondary achalasia. Radiology files from 1989 through 1999 revealed 29 patients with primary achalasia and 10 with secondary achalasia (caused by carcinoma of the esophagus in three, of the gastric cardia in three, of the lung in three, and of the uterus in one) who met our study criteria. The radiographs were reviewed to determine the morphologic features of the narrowed distal esophageal segment and gastric cardia and fundus. Medical records were also reviewed to determine the clinical presentation; endoscopic, manometric, and surgical findings; and treatment. The mean patient age was 53 years in primary achalasia versus 69 years in secondary achalasia (p = 0.03). The mean duration of dysphagia was 4.5 years in primary achalasia versus 1.9 months in secondary achalasia (p <0.0001). The narrowed distal esophageal segment had a mean length of 1.9 cm in primary achalasia versus 4.4 cm in secondary achalasia (p < 0.0001), and the esophagus had a mean diameter of 6.2 cm in primary achalasia versus 4.1 cm in secondary achalasia (p <0.0001). The narrowed segment was eccentric or nodular or had abrupt proximal borders in only four of 10 patients with secondary achalasia, and evidence of tumor was present in the gastric fundus in only three. When findings of achalasia are present on barium studies, a narrowed distal esophageal segment longer than 3.5 cm with little or no proximal dilatation in a patient with recent onset of dysphagia should be considered highly suggestive of secondary achalasia, even in the absence of other suspicious radiographic findings.