A 62-year-old man comes to the physician complaining of dysphagia for both solids and liquids for the past 3 months. He also reports a bad taste in his mouth and frequent regurgitation. He has lost 10 pounds (4.5 Kg) in the last 2 months. His past medical history is significant for hypertension, chronic low back pain, and diverticulitis. There is no family history of malignancy. He has a 20-pack-year smoking history and drinks 2-3 beers daily.
The patient's blood pressure is 142/78 mm Hg and pulse is 92/min. His BMI is 25 kg/m². Physical examination shows poor dentition and halitosis. The remainder of the examination is within normal limits.
His barium swallow is shown in this exhibit.
Which of the following is the best next step in management of this patient?

Question

A 62-year-old man comes to the physician complaining of dysphagia for both solids and liquids for the past 3 months. He also reports a bad taste in his mouth and frequent regurgitation. He has lost 10 pounds (4.5 Kg) in the last 2 months. His past medical history is significant for hypertension, chronic low back pain, and diverticulitis. There is no family history of malignancy. He has a 20-pack-year smoking history and drinks 2-3 beers daily.
The patient's blood pressure is 142/78 mm Hg and pulse is 92/min. His BMI is 25 kg/m². Physical examination shows poor dentition and halitosis. The remainder of the examination is within normal limits.
His barium swallow is shown in this exhibit.

Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation with dysphagia, regurgitation, and mild weight loss, and barium swallow findings (classic "bird-beak" appearance in the terminal esophagus) suggest achalasia. However, he is elderly (> 60 years) and had a rather acute onset of dysphagia (< 6 months). Pseudoachalasia from tumor at the gastroesophageal junction should be suspected. Barium swallow study is preferred to screen for achalasia and usually shows a dilated esophagus with bird-beak narrowing at the terminal and aperistalsis during fluoroscopy. Manometry can confirm the diagnosis and shows elevated lower esophageal sphincter (LES) pressure and incomplete relaxation as well as aperistalsis. However, manometry cannot differentiate between primary idiopathic achalasia and pseudoachalasia. As a result, endoscopy is recommended prior to manometry in all suspected cases of pseudoachalasia to rule out malignancy (Choice B). Endoscopy may show a dilated esophagus with residual food debris, possible inflammation or ulceration, and Candida infection from esophageal stasis. The LES may not open spontaneously, but the scope can be advanced into the stomach with gentle pressure. However, in cases of neoplasm or strictures, it is not possible to advance the scope into the stomach. Achalasia treatment consists of medical therapy (eg, nitrates and calcium channel blockers) or botulinum toxin injection for patients at poor operative risk. Patients who are generally healthy and can tolerate surgery can undergo pneumatic dilatation or surgical myotomy (Choice D). (Choice A) CT scan of the chest may show tumor at the gastroesophageal junction, but endoscopy will still be required to obtain tissue diagnosis and should be performed next in this patient. (Choice E) Starting the patient on a proton-pump inhibitor may reduce some symptoms of reflux but will not solve the problem of dysphagia or regurgitation caused by achalasia. Educational objective: Pseudoachalasia differs from classic achalasia in that it is caused by a tumor at the gastroesophageal junction and not through impairment of LES relaxation. It should be considered in older patients (> 60 years), those with shorter symptom duration (< 6 months), or acute weight loss. Diagnosis is made by barium swallow followed by endoscopy. __________ References: Achalasia secondary to neoplasia: a disease with a changing differential diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/21967574) Treatment of the patient with achalasia. (http://www.ncbi.nlm.nih.gov/pubmed/22508324)

A 62-Year-Old Man Comes to the Physician Complaining of Dysphagia