A 55-year-old man presents with dysphagia to solids only, progressive over 6 months, with regurgitation of undigested food, and no heartburn. Barium swallow shows a 'bird-beak' tapering at the lower esophagus. Esophageal manometry shows absent peristalsis and incomplete lower esophageal sphincter relaxation. High-resolution manometry confirms integrated relaxation pressure (IRP) >15 mmHg. The diagnosis is:
- A Diffuse esophageal spasm
- B Scleroderma esophagus
- C Achalasia (type I — classic achalasia) ✓
- D Esophageal carcinoma with secondary achalasia
Explanation
The classical features of achalasia are absent peristalsis and impaired LES relaxation on high-resolution manometry — specifically, IRP >15 mmHg (with Zenith reference values) is the key criterion. The 'bird-beak' sign on barium swallow reflects the non-relaxing LES. Type I achalasia shows absent peristalsis with minimal pressurization; type II shows pan-esophageal pressurization (best prognosis); type III shows spastic contractions. Scleroderma esophagus shows absent peristalsis but a low-pressure, HYPOTENSIVE LES that relaxes appropriately. DES shows premature contractions. Secondary achalasia (pseudoachalasia) must be excluded with upper endoscopy.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.