With the increasing availability of manometry, patients with achalasia are often referred at an early stage when they lack the classic features of established disease. A prospective five year study of the presenting features of untreated achalasia referred to our department was undertaken. Twenty men and 18 women presented throughout adult life, with a mean age at the time of diagnosis of 44 years (range 17 to 76 years). The presenting symptoms were dysphagia: for solids (100%) and for liquids (97%), chest pain (74%), and weight loss (60%). Endoscopy was reported as normal in 15 patients and achalasia was suggested in only 21 of 33 barium examinations. Fourteen had been treated for gastrooesophageal reflux but none had been misdiagnosed as having cardiac or psychiatric disease. The annual incidence of achalasia in the Lothian region is 0.8/100,000 of population. Persistent dysphagia is the cardinal symptom of achalasia which presents throughout adult life. Nevertheless, recent onset achalasia is often misdiagnosed as gastrooesophageal reflux disease. Because endoscopy is frequently normal and the diagnosis is often not made by radiology, manometric investigation is necessary if the condition is to be recognised and treated at an early stage.

https://gut.bmj.com/content/gutjnl/33/8/1011.full.pdf

Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh.

Objective Pseudoachalasia frequently cannot be distinguished from idiopathic achalasia by manometry, radiologic examination or endoscopy. Mechanisms proposed to explain the clinical features of pseudoachalasia include a circumferential mechanical obstruction of the distal esophagus or a malignant infiltration of inhibitory neurons within the myenteric plexus. Material and methods Between January 1980 and December 2002, the clinical features of 5 patients with pseudoachalasia and 174 patients with primary achalasia, diagnosed in a single center, were compared. A literature analysis of the etiology of pseudoachalasia for the time period 1968 to December 2002 was performed. The search concentrated on the databases and online catalogues PubMed, Web of Science, Cochrane Library and Current Contents Connect. Results In our case series, patients with pseudoachalasia reported a shorter duration of symptoms and tended to be older than patients with primary achalasia. Conventional manometry, endoscopy and radiologi...

Pseudoachalasia: a case series and analysis of the literature.

Motility disorders of the esophagus.

In this Review, the author focuses on the diagnostic evaluation of dysphagia, a disorder that is common in the general population and even more so in the elderly and in the chronic-care setting. In particular, the importance of taking a good history is emphasized. Consideration is also given to interpreting the findings of radiography, endoscopy and esophageal manometry, and what to do when these three modalities fail to yield a diagnosis. Taking a careful history is vital for the evaluation of dysphagia. The history will yield the likely underlying pathophysiologic process and anatomic site of the problem in most patients, and is crucial for determining whether subsequently detected radiographic or endoscopic 'anomalies' are relevant or incidental. Although the symptoms of pharyngeal dysphagia can be multiple and varied, the typical features of neurogenic pharyngeal dysphagia are highly specific, and can accurately distinguish pharyngeal from esophageal disorders. The history will also dictate whether the next diagnostic procedure should be endoscopy, a barium swallow or esophageal manometry. In some difficult cases, all three diagnostic techniques may need to be performed to establish an accurate diagnosis. Stroke is the most common cause of pharyngeal dysphagia. A videoradiographic swallow study is vital in such cases to determine the extent and timing of aspiration and the severity and mechanics of dysfunction as a prelude to therapy.

Diagnostic evaluation of dysphagia.

Background Minimally invasive surgery has assumed an ever-expanding role in gastrointestinal surgery since the introduction of laparoscopic cholecystectomy. This review describes some of the more common minimally invasive procedures of the esophagus and stomach, with particular attention to technique. Data Sources A literature review of minimally invasive surgery of the esophagus and stomach was conducted. Conclusions Laparoscopic (and thoracoscopic) approaches for gastroesophageal reflux disease appear to have excellent operative and short-term follow-up results. Long-term follow-up data, however, remain unobtainable for several more years. Limited reports of esophageal cardiomyotomy, paraesophageal hernia repair, and gastric surgery for peptic ulcer disease performed through a minimally invasive approach are encouraging. Experience with resection of esophageal and gastric neoplasia is limited to a few specialized centers. Results should be scrutinized and compared with open operation before proclaiming the benefits of a minimally invasive approach.

Minimally invasive surgery of the esophagus and stomach

An impression that achalasia remains an elusive diagnosis led us to review our recent experience From August 1, 1985 to March 31, 1987, we saw 25 patients with "previously untreated" achalasia for consultation and/or treatment Data was extracted from review of their records Achalasia was the initial diagnosis in only 12 patients The others were given diagnoses of gastroesophageal reflux (4), presbyesophagus (2), esophageal spasm (2), psychiatric disorders (2), and combination of various disorders (3) In the latter patients, various diagnostic studies were either inappropriately delayed or misinterpreted, so that incorrect diagnoses were given Errors in diagnosis led to further inappropriate testing and therapies We conclude that: (a) achalasia remains an elusive diagnosis in current practice, (b) errors in diagnosis are related to delay in obtaining appropriate studies or misinterpretation of such studies, and (c) this delay leads to persistent symptoms and ineffective and/or inappropriate therapies

Seth Rosenzweig

Papers

The diagnosis and misdiagnosis of achalasia: a study of 25 consecutive patients