Personal Approach

I virtually always begin evaluation of unexplained dysphagia with barium studies (Figure 19-1). More mistakes are made by leaping directly to endoscopy than for any other reason. Once the diagnosis of achalasia is suggested by barium esophagram, assuming an endoscopy has not already been performed, I perform an endoscopy to rule out benign or malignant stricture. Clues to an alternative diagnosis include an obvious fungating mass lesion obstructing the lumen, significant erosive disease, inability or excessive resistance to intubate the EG junction, and a mass on retroflexed view of the gastric cardia and fundus.

In the face of a consistent barium esophagram and in absence of any of these suspicious findings, the diagnosis of achalasia is virtually assured. As based on currently available sutides, neither LES pressure nor the category of achalasia would be likely to change my therapeutic decisions; manometry is of interest, but is not essential before treatment. Although the distinction between vigorous and classic achalasia have prognostic significance, my treatment approach is not dramatically altered by the category of achalasia. If there is doubt after endoscopy, a computed tomography scan and endoscopic ultrasound (EUS) are

FIGURE 19-1. The barium study shows a dilatated esophagus with a column of barium mixed with retained food and an air-fluid level at the top, extending up from a smooth tapered stenotic EG junction.

more likely to help in the diagnosis of a cancer posing as achalasia than is manometry.

As mentioned, continued observation is rarely an option. Nonetheless the urgency of treatment is increased by a history suggesting a high aspiration risk and by the degree of weight loss. I often suggest an empirical trial of carbonated beverage with meals or just before bedtime to see if I can improve the patient's symptoms pending arrangement for treatment. If nighttime coughing is a problem, the patient should avoid lying down within a few hours of eating and should elevate the head of the bed. I may use a short acting sublingual nitroglycerin for the patient who has intermittent chest pain or a longer acting sublinqual nitrate for temporary alleviation of symptoms if other interventions must be delayed. However, given the limited response and frequent side effects, I do not generally recommend the long term use of smooth muscle relaxants unless the patient refuses alternative treatment options.

Constipation Prescription

Constipation Prescription

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