A 42 year old mechanic has a three month history of progressive dysphagia and marked

Discussion in 'Plab 1 and 2 forum' started by Neha Gupta, Jun 19, 2013.

  1. Neha Gupta

    Neha Gupta Active Member

    A 42 year old mechanic has a three month history of progressive dysphagia and marked weight loss. He describes a senstation of sticking of both solid food and liquids behind his sternum. He has effortless regurgitation after eating, particularly on bending forward or reclining. This is not associated with a sour taste. A plain chest X-ray demonatrates a high air/fluid level behind the heart. On endoscopy the esophagoscope can easily be passed into the stomach A likely diagnosis is
    a) Candida albicans
    b) pharyngeal pouch
    c) esophageal diverticulum
    d) achalasia
    e) rolling hiatus hernia
    f) Rhabdomyoma
    g) sliding hiatus hernia
    h) upper esophageal web
    i) scleroderma
    j) Kaposi\'s sarcoma
  2. Neha Gupta

    Neha Gupta Active Member

    Answer: D.

    The two most common symptoms of achalasia are dysphagia (inability to swallow) and regurgitation. A spastic variant of the disease can present with chest pain and dysphagia. Dysphagia is usually observed early in the evolution of the disease, and is caused by the inability of the LES to relax. As the esophagus becomes progressively dilated and accumulates large amounts of solid food, overflow regurgitation occurs. Due to a reclining position, regurgitation during the night can lead to aspiration pneumonia and pulmonary abscesses. Stress or the ingestion of cold liquids may aggravate the symptoms. Retrosternal pain on swallowing (odynophagia) is not characteristic of achalasia but may occur in the early stages of the disease. Achalasia is insidious, as patients may not notice impairment of esophageal emptying for months to years. Inability to adequately swallow leads to weight loss in more than half of these patients. Diagnosis requires the use of esophageal manometry, endoscopy, and radiography. Manometry is the diagnostic test of choice when achalasia is suspected. Typical findings include impaired esophageal peristalsis (either spastic or without motility), inability of the esophagus to relax to the zero baseline, and hypertensive LES. Endoscopy must be performed in all patients to rule out more common causes of dysphagia such as Schatzki ring, benign strictures, or malignancy. A dilated esophagus with a tight LES is characteristic of achalasia. The esophagoscope can easily be passed through the LES into the stomach except in patients with malignant strictures. Barium esophogram will have typical findings of a \'bird-beak\' appearance at the distal esophagus and a dilated proximal esophagus. Air or fluid behind the heart is occasionally seen on plain chest X-rays. Endoscopic ultrasound of the esophagus is also helpful and usually shows a thickened hypertrophic inner layer of the muscularis propria of the esophagus.

Share This Page