Diagnosis

One function of endoscopy is to confirm the diagnosis suggested by radiographs and manometry. A more important role is to exclude a malignant stricture by endoscopic biopsy. Radiographs cannot positively exclude a carcinoma of the cardia or distal esophagus. Moreover, achalasia itself is a premalignant condition with a long-term cancer risk of approximately 3 %.

Studies and Measures Prior to Endoscopy

If achalasia is suspected or known to be present, or if fluid and food residues are detected in the esophagus at the start of en-doscopy, the following measures may be indicated:

► Chest radiograph: mediastinal widening?

► Oral contrast study: dilated esophagus over the funnel-shaped constriction of the LES

► Fasting for 24 hours

► Any fluid residues are suctioned from the esophagus

► Examination may be aided by head-down tilt

► Use an endoscope with a large suction channel

Endoscopic diagnostic criteria

Early:

- Endoscopy may show no abnormalities

- Increased, "springy" resistance to instrument passage

- Failure of the cardia to open during prolonged observation (Fig. 3.50)

- Persistent rosette appearance

- Retroflexed view: cardia tightly closed around the endoscope

- Food residues and fluid in the esophagus

- Esophagus dilated, lax, elongated, tortuous

- Uncoordinated, nonpropulsive, or absent contractions

- Diverticulumlike pouch above the LES

- Increased resistance to cardial intubation

- Mucosal changes due to food retention: padlike thickening of the mucosa, erythema, petechiae, grayish-yellow deposits, rarely erosions, very rarely ulcerations

Differential diagnosis

Malignant stricture (usually more difficult to intubate) Caution: A small cardia carcinoma may be missed in the forward view, so always inspect closely in retroflex-ion and take a generous tissue sample.

Checklist for endoscopic evaluation

Evaluate the contents, shape, length, and course of the esophagus.

Evaluate esophageal contractions.

Observe, inspect, and evaluate the LES in forward and retroflexed views.

Evaluate mucosal changes.

Additional Studies

► Oral contrast study: typical findings, see above

► Manometry: elevated pressure in the LES, absence of propulsive peristalsis

► Endosonography: thickening of the muscularis; detect or exclude cardia carcinoma

Fig. 3.50 Achalasia. Sustained contraction of the LES

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TO u

Fig. 3.51 Achalasia a Marked prestenotic dilatation

Fig. 3.51 Achalasia a Marked prestenotic dilatation

c Chronic inflammatory mucosal changes proximal to the stenosis

b Prestenotic pooling of secretions

d Diverticulumlike dilatation proximal to the stenosis

Fig. 3.52 Manometric findings in hy-pomotile achalasia. The manometric traces show simultaneous hypotonic contractions in the tubular esophagus, with failure of the LES to relax with swallowing (from: Hahn and Riemann, Klinische Gastroenterologie. Vol. I, 3 rd ed. Stuttgart: Thieme 1996) les = lower esophageal sphincter sw = swallow c Chronic inflammatory mucosal changes proximal to the stenosis d Diverticulumlike dilatation proximal to the stenosis

Fig. 3.52 Manometric findings in hy-pomotile achalasia. The manometric traces show simultaneous hypotonic contractions in the tubular esophagus, with failure of the LES to relax with swallowing (from: Hahn and Riemann, Klinische Gastroenterologie. Vol. I, 3 rd ed. Stuttgart: Thieme 1996) les = lower esophageal sphincter sw = swallow

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