Case presentation

1. Sandra Saju
9th semester

2. 58 year old female presented with chief complaint of dysphagia.
She was in good health until 7 months before when she first noted
occasional difficulty eating solid food.
She used to have a sensation that food was lodged in her chest which
would persist for several hours. These episodes became more
frequent over time and she began having difficulty ingesting both
liquids and solids.
Her history was significant for a 13-14 Kg weight loss over a 2-month
period, 2 bouts of pneumonia in the past 3 months, and chronic
heartburn treated with over the counter antacids
She also gives history of regurgitation and at times had to induce emesis
for symptom relief.
Apart from the above complaints, she did not have any other complaint.
Occassional Smoker; Non-alcoholic.
Blood test were normal except evidence of mild Anemia with hemoglobin 11.5 g/dL,
hematocrit of 38.9%, and MCV of 81 fL.

3. 58 year old female presented with chief complaint of dysphagia.
She was in good health until 7 months before when she first noted
occasional difficulty eating solid food.
She used to have a sensation that food was lodged in her chest which
would persist for several hours. These episodes became more
frequent over time and she began having difficulty ingesting both
liquids and solids.
Her history was significant for a 13-14 Kg weight loss over a 2-month
period, 2 bouts of pneumonia in the past 3 months, and chronic
heartburn treated with over the counter antacids
She also gives history of regurgitation and at times had to induce emesis
for symptom relief.
Apart from the above complaints, she did not have any other complaint.
Occassional Smoker; Non-alcoholic.
Blood test were normal except evidence of mild Anemia with hemoglobin 11.5 g/dL,
hematocrit of 38.9%, and MCV of 81 fL.

4. While doing endoscopy there is an inability to pass the endoscope into
the stomach.
A Barium swallow was done showing narrowing in the distal esophagus
(BIRD BEAK SIGN) with significant dilatation and hold up of contrast
in the proximal esophagus.
Filling defects in the distal esophageal segment were noted.
Manometric findings indicates Esophageal Motility disorder.
Amyl nitrate was administered , but there was no response.
What Will Be Your Diagnosis?
Would You Advice any other Investigation?

6. Achalasia cardia is due to loss of myenteric ganglion cells in the gastroesophageal
junction and the etiology is idiopathic.
In true or primary achalasia, there is loss of peristalsis in esophageal body and failure
of LES to relax when swallowing.
Presents with dysphagia to both solids and liquids with regurgitation of food from the
esophagus
It’s often associated with Aspiration pneumonia.
Barium swallow shows a typical bird's beak appearance.

7. A similar clinical picture can be produced by other diseases,
Secondary Achalasia  ass. With underlying pathologies(e.g.,
Chaga’s Disease)
or pseudoachalasia malignancy associated
Primary malignancy of esophagus or gastroesophageal junction (>50 % of
Cases).

8. To differentiate Pseudoachalasia from primary Achalasia
In Pseudoachalasia
Barium swallow shows nodular or shouldered segment of
distal esophageal narrowing.
The length of the narrowed segment was found to be >3.5 cm in
80% of the patients which is the most important feature in
radiological differentiation.
A CT scan may show asymmetric thickening of the esophageal
wall or cardia, mediastinal lymphadenopathy or may identify
primary malignancy in secondary achalasia.
Gastroscopic Biopsy helps to Confirm the Diagnosis.

9. Treatment
 Surgical Resection of the mass.
 Adjuvant Chemotherapy
 Symptomatic treatment and
 Palliative care is indicated in advanced cases.

10. REFERENCES
• Harrisson’s Principles of Internal Medicine, 19th edition, Chapter No. 112, page No. 554-557
• http://www.ijri.org/article.asp?issn=0971-3026;year=2015;volume=25;issue=3;spage=288;epage=295;aulast=Gupta
• http://manju-imagingxpert.blogspot.com/2009/12/pseudoachalasia-of-cardia_29.html
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4219883/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630955/#idm140665933445840title