How Do You Distinguish Achalasia From Other Causes of Dysphagia?

Answer in brief: Achalasia is suggested by dysphagia to both solids and liquids, regurgitation and retained esophageal contents, but symptoms alone are not diagnostic. Upper endoscopy is needed to exclude mechanical obstruction and pseudoachalasia; timed barium esophagram can show impaired emptying; high-resolution manometry establishes the diagnosis and defines achalasia subtype.[1]

History gives the first clue

Mechanical obstruction often begins with solid-food dysphagia and later progresses to liquids. Achalasia commonly causes difficulty with solids and liquids from early in the course, with regurgitation, chest discomfort and weight loss. These patterns are helpful but imperfect.

Endoscopy must exclude pseudoachalasia

A tight gastroesophageal junction with retained saliva or food can suggest achalasia, but malignancy at the cardia or distal esophagus can mimic it. Older age, rapid progression and marked weight loss should heighten suspicion for pseudoachalasia and may justify CT and/or EUS in addition to endoscopy.

Timed barium esophagram adds functional anatomy

Classic findings include esophageal dilation, retained barium and tapering at the gastroesophageal junction. Timed measurements quantify emptying and can also help assess response after therapy.

High-resolution manometry is definitive

Manometry demonstrates impaired lower-esophageal-sphincter relaxation and absent normal peristalsis, then classifies achalasia into clinically useful subtypes. Subtyping influences expected response to pneumatic dilation, Heller myotomy and POEM.

FLIP is an important adjunct

Functional lumen imaging probe can measure EGJ distensibility during sedated endoscopy and can be particularly useful when manometry is equivocal or difficult to complete. It complements rather than replaces careful structural evaluation.

Do not miss alternative motor disorders

EGJ outflow obstruction, distal esophageal spasm, hypercontractile esophagus and severe ineffective motility can all produce dysphagia. Chicago Classification principles and the clinical context prevent overcalling incidental manometric patterns.

Questions trainees should be able to answer

Which symptom pattern raises suspicion for achalasia?
Why must endoscopy precede or accompany physiologic testing?
What are the complementary roles of timed barium esophagram, HRM and FLIP?

Frequently asked questions

Can achalasia cause heartburn-like symptoms? Yes. Retained food and fermentation can produce burning or regurgitation and lead to mistaken GERD treatment.

What is pseudoachalasia? An achalasia-like syndrome caused by a mechanical or infiltrative process, most importantly malignancy.

Is manometry required? High-resolution manometry is the standard test to establish and subtype achalasia when feasible.

Free further reading from Dr. Thomson

GI Practice Review — free book library
Scientific Basis for Clinical Practice in Gastroenterology and Hepatology — free book library

References

1. Vaezi MF, Pandolfino JE, Yadlapati RH, et al. ACG Clinical Guideline: Diagnosis and Management of Achalasia. Am J Gastroenterol. Updated guideline.

2. Gyawali CP, Carlson DA, Chen JW, et al. ACG Clinical Guidelines: Clinical Use of Esophageal Physiologic Testing. Am J Gastroenterol. 2020;115:1412-1428.

3. Thomson ABR. Practice Review in Gastroenterology. CAPstone Academic Publishers; 2014.

Educational use only. This article is intended for clinicians and trainees and does not replace patient-specific medical judgment or local guidance.