Diagnosis of cardiac achalasia

Suspicion of achalasia of cardia occurs when patients are presented with typical complaints of difficulty swallowing in combination with pain after the sternum after a meal, regurgitation (regurgitation), frequent attacks of hiccoughs, belching and weight loss.

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

 Careful inquiry of the patient is especially necessary to identify typical cardiac symptoms for achalasia.

• Whether the occurrence of swallowing difficulties depends on the consistency of food (dense, liquid). The difficulty of swallowing only dense food is usually associated with structural changes in the esophagus (peptic stricture, cancer, etc.), whereas the emergence of dysphagia when swallowing both solid and liquid food is more typical for cardiac achalasia.
• Does difficulty swallowing when consuming cold or carbonated drinks.
• What methods does the patient use to facilitate swallowing, such as eating standing.
• Whether pain in the chest is associated with eating or with physical stress (it is necessary to differentiate the esophageal and coronary pains).
• Does the patient have a regurgitation of food that does not have a sour taste (because the food during achalasia is delayed in the esophagus with an alkaline medium).
• Does the patient wake up from a cough associated with regurgitation, and whether there are signs of food on the pillow in the morning (a symptom of a "wet pillow").
• How quickly weight loss progresses. How much the patient has hiccups and belching with air.

The following points are especially important in the examination:

• Detection of weight loss.
• Detection of stridorous respiration due to the presence in the upper respiratory tract of a foreign body of esophageal origin.
• Identification of signs of aspiration pneumonia.
• Investigation of cervical, supraclavicular and peripump lymph nodes for the timely detection of possible metastatic foci of esophageal cancer, which also manifests itself by dysphagia.
• Careful palpation of the liver is also for the detection of metastases.

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Indications for consultation of other specialists

Occur with difficulty in differential diagnosis. Consultations of the following specialists are recommended:

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

Laboratory diagnostics of cardiac achalasia

Recommended survey methods:

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

Instrumental diagnosis of achalasia of the cardia

Compulsory methods of examination:

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

Signs of achalasia of cardia:

• Extended lumen of the esophagus.
• Absence of gas bubble of the stomach.
• Delayed release of the esophagus from the contrast medium.
• Narrowing of the terminal section of the esophagus ("candle flame").
• Lack of normal peristaltic contractions of the esophageal wall.
• During the study, it is necessary to make sure that there is no hernia of the esophageal opening of the diaphragm, fixed esophageal strictures and tumor formations.

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

FEGS to exclude pseudo-achalasia (narrowing of the esophagus, due to various causes, for example adenocarcinoma of the cardial esophagus) and pathological changes in the mucous membrane of the upper gastrointestinal tract.

Endoscopic signs of achalasia:

• Extended lumen of the esophagus.
• Presence of food masses in the esophagus.
• The narrowing of the cardial opening of the esophagus and its minimal opening when air is injected into the esophagus, however, when the tip of the endoscope passes through this hole, the sensed resistance is small (if the perceived resistance is quite significant, then the probability of narrowing of tumor origin is high).
• The absence of hernia of the esophagus of the diaphragm and the esophagus of Barrett.

Sensitivity of PHEGS for detection of achalasia is lower than in radiocontrast study, 29-70%, specificity is the same - 95%. To detect a narrowing of the esophagus of organic nature, the sensitivity of the PHEGS should be 76-100%.

Recommended research:

The study of the motor function of the esophagus is esophageal manometry.

Characteristic signs of achalasia of 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 time of swallowing;
• increased pressure in the lower esophageal sphincter;
• increased intra-esophageal pressure in the intervals between swallowing movements.

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

ECG (preferably during an attack of pain in the chest) to exclude possible IHD.

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

Additional instrumental research methods are used to identify the pathology of adjacent organs or if a differential diagnosis is necessary:

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

Differential diagnosis of cardiac achalasia

Differential diagnosis is performed with the following diseases.

Oesophageal narrowing due to tumor lesion of the lower esophageal sphincter region: clinical manifestations are similar to those with true achalasia, but with careful examination it is possible to detect lymphadenopathy, hepatomegaly, palpable formation in the abdominal cavity. For differential diagnosis, PHAGS is especially needed.

Gastroesophageal reflux disease. The main symptoms are heartburn (burning behind the sternum) and regurgitation of acidic gastric contents. Dysphagia is a less common symptom due to complications in the form of peptic stricture or peristalsis of the esophagus. Difficulty swallowing is more typical when swallowing dense food / liquid food is good. The lumen of the esophagus is not enlarged. In the vertical position, the contrast in the esophagus does not linger, unlike the achalasia of the cardia. With EEGD, erosions or changes typical of Barrett's esophagus can be identified.

IHD. Clinical characteristics of pain are indistinguishable from those of cardiac achalasia (especially when angina pain is provoked by eating), however, dysphagia for angina is not characteristic. Differentiation is also made difficult by the fact that achalasia pains can also be stopped by nitroglycerin. It is necessary to conduct an electrocardiogram and, in case of doubt in the diagnosis, a comprehensive examination to detect myocardial ischemia.

Congenital membranes of the esophagus, strictures, including those caused by tumors: dysphagia is typical, especially when taking dense food; in some cases, there is vomiting and regurgitation of delayed esophageal contents.

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

Other diseases: esophagospasm, esophageal damage in scleroderma, pregnancy, Chagas disease, amyloidosis, Down's disease, Parkinson's disease, Ollgrove's syndrome.

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