A 43-year-old man is evaluated for retrosternal discomfort and dysphagia for the past several months. He smokes a pack of cigarettes daily and drinks alcohol on weekends. His BMI is 32.8 kg/m². Physical examination is unremarkable. Esophageal manometry is performed; after a single swallow of 5 mL of water, the tracings appear as shown in the image below. Which of the following is the most likely diagnosis in this patient?

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11ec160b_3ad4_5cf1_9249_47ce5431c5a1_MD0001_00 To initiate swallowing, the contents of the oral cavity are collected on the tongue and propelled into the pharynx, where contraction of the pharyngeal muscles pushes the material into the esophagus. The cricopharyngeus muscle contracts behind the food bolus, initiating a peristaltic wave to propel the bolus downward. When the food bolus reaches the lower esophagus, the lower esophageal sphincter (LES) relaxes to allow the material to enter the stomach. Achalasia is a motility disorder caused by reduced numbers of inhibitory ganglion cells in the esophageal wall, which creates an imbalance favoring excitatory ganglion cells. This patient's esophageal manometry shows typical findings in achalasia, including normal contraction of the upper esophageal sphincter, decreased amplitude of peristalsis in the mid esophagus, and increased tone and incomplete relaxation at the LES. Patients experience dysphagia, regurgitation, and retrosternal chest pain. Barium esophagram typically shows dilation of the esophagus with distal narrowing. (Choice B) Cricopharyngeal dysfunction results from failure of the cricopharyngeus to relax during swallowing and causes a choking or "food-sticking" sensation on swallowing. Manometry findings are variable and can show decreased pharyngeal tone or incomplete relaxation at the upper esophageal sphincter. (Choice C) Diffuse esophageal spasm presents with severe, retrosternal chest pain. It is characterized by uncoordinated contractions of the esophageal body. Esophageal manometry shows intermittent peristalsis and multiple simultaneous contractions on tracings from the mid and lower esophagus. (Choice D) Esophageal stricture presents with progressive solid food dysphagia. It is diagnosed with contrast imaging (eg, barium swallow) rather than manometry. However, most patients will have a long history of gastroesophageal reflux with decreased tone at the LES. (Choice E) Systemic sclerosis (scleroderma) can affect the esophagus, leading to impaired motility, incompetence of the LES, and gastroesophageal reflux. Manometry will show decreased peristalsis with decreased tone at the LES. Educational objective: Achalasia is caused by reduced numbers of inhibitory ganglion cells in the esophageal wall. Esophageal manometry in achalasia shows decreased amplitude of peristalsis in the mid esophagus, with increased tone and incomplete relaxation at the lower esophageal sphincter.

A 43-Year-Old Man Is Evaluated for Retrosternal Discomfort and Dysphagia