Diagnosis of achalasia of the cardia

Achalasia of the cardia is suspected when patients present typical complaints of difficulty swallowing combined with pain behind the breastbone after eating, regurgitation, frequent bouts of hiccups, belching, and weight loss.

The examination should include an X-ray examination of the esophagus with a barium sulfate suspension, fibroesophagogastroduodenoscopy (FEGDS), esophageal manometry and electrocardiography (ECG). It is this combination of diagnostic methods that allows us to establish the presence of achalasia of the cardia and exclude diseases with a similar clinical picture.

A thorough questioning of the patient is especially necessary to identify symptoms typical of achalasia of the cardia.

• Does the occurrence of swallowing difficulties depend on the consistency of food (solid, liquid). Difficulty in swallowing only solid food is usually associated with structural changes in the esophagus (peptic stricture, cancer, etc.), while the occurrence of dysphagia when swallowing both solid and liquid food is more typical for achalasia of the cardia.
• Does difficulty swallowing increase when drinking cold or carbonated drinks?
• What techniques does the patient use to make swallowing easier, such as eating while standing.
• Are chest pains associated with eating or physical exertion (it is necessary to differentiate between esophageal and coronary pain).
• Does the patient regurgitate food that does not have a sour taste (since food in achalasia is retained in the esophagus with an alkaline environment).
• Does the patient wake up from a cough associated with regurgitation, and are there traces of food on the pillow in the morning (the “wet pillow” symptom?).
• How fast is weight loss progressing? How severe is the patient's hiccups and belching?

The following points are especially important during the examination:

• Detection of weight loss.
• Detection of stridor breathing due to the presence of a foreign body of esophageal origin in the upper respiratory tract.
• Identifying signs of aspiration pneumonia.
• Examination of the cervical, supraclavicular and periumbilical lymph nodes for the timely detection of possible metastatic foci of esophageal cancer, which also manifests itself as dysphagia.
• Careful palpation of the liver - also to detect metastases.

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Indications for consultation with other specialists

Occurs when there are difficulties in differential diagnosis. Consultations with the following specialists are recommended:

• cardiologist - if ischemic heart disease (IHD) is suspected:
• an oncologist - if an organic cause of dysphagia is identified; a psychiatrist - if a neurogenic cause of dysphagia (anorexia) is suspected.

Laboratory diagnostics of achalasia of the cardia

Recommended examination methods:

• general blood test with determination of reticulocyte content;
• coagulogram;
• serum creatinine level;
• serum albumin level;
• general urine analysis.

Instrumental diagnostics of achalasia of the cardia

Mandatory examination methods:

• Contrast X-ray examination of the esophagus and stomach with barium sulfate suspension - in patients with dysphagia with suspected achalasia of the cardia.

Signs of achalasia cardia:

• Dilated lumen of the esophagus.
• Absence of gas bubble in the stomach.
• Delayed release of contrast material from the esophagus.
• Narrowing of the terminal esophagus ("candle flame").
• Absence of normal peristaltic contractions of the esophageal wall.
• During the examination, it is necessary to ensure the absence of a hernia of the esophageal opening of the diaphragm, fixed strictures of the esophagus and tumor formations.

The sensitivity of the method for detecting achalasia of the cardia is 58-95%, specificity is 95%.

FEGDS to exclude pseudoachalasia (narrowing of the esophagus caused by various reasons, such as adenocarcinoma of the cardiac part of the esophagus) and pathological changes in the mucous membrane of the upper gastrointestinal tract.

Endoscopic signs of achalasia:

• Dilated lumen of the esophagus.
• The presence of food masses in the esophagus.
• Narrowing of the cardiac opening of the esophagus and its minimal opening when air is pumped into the esophagus, however, when the tip of the endoscope is passed through this opening, the perceived resistance is small (if the perceived resistance is quite significant, then there is a high probability of narrowing of tumor origin).
• Absence of hiatal hernia and Barrett's esophagus.

The sensitivity of FEGDS for detecting achalasia is lower than that of X-ray contrast examination - 29-70%, the specificity is the same - 95%. To detect esophageal stenosis of organic origin, the sensitivity of FEGDS should be 76-100%.

Recommended studies:

Study of the motor function of the esophagus - esophageal manometry.

Characteristic signs of achalasia of the cardia:

• absence of progressive increase in pressure in the esophagus in accordance with peristaltic contractions of the esophagus;
• absence or incomplete relaxation of the lower esophageal sphincter at the moment of swallowing;
• increased pressure in the lower esophageal sphincter;
• increased intraesophageal pressure between swallowing movements.

The sensitivity of esophageal manometry for detecting achalasia is 80-95%, specificity is 95%.

ECG (preferably during an attack of chest pain) to exclude possible coronary heart disease.

Subsequently, an X-ray examination of the chest, esophagus and stomach is carried out, and a study of the motor function of the esophagus (esophageal manometry) is carried out in dynamics.

Additional instrumental research methods are used to identify pathology of adjacent organs or when it is necessary to conduct a differential diagnosis:

• ultrasound examination of abdominal organs;
• esophageal scintigraphy;
• computed tomography of the chest organs.

Differential diagnostics of achalasia of the cardia

Differential diagnosis is carried out with the following diseases.

Esophageal stenosis due to tumor lesion of the lower esophageal sphincter: clinical manifestations are similar to those of true achalasia, but careful examination may reveal lymphadenopathy, hepatomegaly, and a palpable mass in the abdominal cavity. FEGDS is especially necessary for differential diagnosis.

Gastroesophageal reflux disease. The main symptoms are heartburn (burning behind the breastbone) and regurgitation of acidic gastric contents. Dysphagia is a less common symptom caused by complications in the form of peptic stricture or esophageal peristalsis disorders. Difficulty swallowing is more typical when swallowing solid food/liquid food passes well. The lumen of the esophagus is not dilated. In the vertical position, the contrast in the esophagus is not retained, unlike in achalasia of the cardia. FGDS can reveal erosions or changes typical of Barrett's esophagus.

IHD. According to clinical characteristics, the pain is indistinguishable from that of achalasia of the cardia (especially in cases where angina pain is provoked by food intake), but dysphagia is not typical for angina. Differentiation is also complicated by the fact that pain in achalasia can also be relieved by nitroglycerin. It is necessary to conduct an ECG and, if there is any doubt about the diagnosis, a comprehensive examination to identify myocardial ischemia.

Congenital esophageal membranes, strictures, including those caused by tumors: dysphagia is characteristic, primarily when eating solid food; in some cases, vomiting and regurgitation of retained esophageal contents occur.

Neurogenic anorexia. Possible neurogenic dysphagia is usually accompanied by vomiting (of gastric contents) and weight loss.

Other diseases: esophageal spasm, esophageal lesions in scleroderma, pregnancy, Chagas disease, amyloidosis, Down syndrome, Parkinson's disease, Allgrove syndrome.

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