Achalasia differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Achalasia}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Achalasia]]
{{CMG}}, {{AE}} {{AY}}
{{CMG}}, {{AE}} {{AY}}


==Overview==
==Overview==
Achalasia must be differentiated from other causes of dysphagia, odynophagia and food regurgitation such as GERD, esophageal adenocarcinoma and esophageal stricture.
Achalasia must be differentiated from other causes of [[dysphagia]], [[odynophagia]] and food [[regurgitation]] such as [[GERD]], [[Esophageal carcinoma|esophageal adenocarcinoma]], [[esophageal stricture]], [[esophageal webs]], [[motor disorders]] such as [[myasthenia gravis]], [[stroke]], [[Zenker's diverticulum]], [[diffuse esophageal spasm]], [[systemic sclerosis]] and [[Plummer-Vinson syndrome|Plummer Vinson syndrome]].


== Differentiating Achlasia from other Disease==  
== Differentiating Achlasia from other Disease==  
Achalasia must be differentiated from other causes of dysphagia, odynophagia and food regurgitation such as GERD, esophageal adenocarcinoma and esophageal stricture.
 
Achalasia must be differentiated from other causes of [[dysphagia]], [[odynophagia]] and food regurgitation such as [[GERD]], [[Esophageal carcinoma|esophageal adenocarcinoma]] and [[esophageal stricture]].
 
<small>
{| class="wikitable"
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Disease
! colspan="8" style="background:#4479BA; color: #FFFFFF;" align="center" |Signs and Symptoms
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Barium esophagogram
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Endoscopy
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Other imaging and laboratory findings
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Gold Standard
|-
| rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Onset
| colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Dysphagia
| rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss
| rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Heartburn
| rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Other findings
| rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Mental status
|-
| style="background:#4479BA; color: #FFFFFF;" align="center" |Solids
| style="background:#4479BA; color: #FFFFFF;" align="center" |Liquids
| style="background:#4479BA; color: #FFFFFF;" align="center" |Type
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Plummer-Vinson syndrome]]
|
* Gradual
| +
| -
|Non progressive
| +/-
| -
|
* [[Glossitis]]
 
* [[Koilonychia]]
 
|Normal
|
* Thin projections on the anterior [[esophageal]] wall
* Multiple upper [[Esophageal stricture|esophageal constrictions]]
[[Image:Plummer-vinson-syndrome.jpg|center|200px|thumb|Barium esophagogram (Source: Case courtesy of Dr Hani Salam, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/14029">rID: 14029</a>)]]
|
* Direct visualization of [[esophageal webs]]
* Superior to [[esophagogram]]
<div style="width:350px">{{#ev:youtube|HFfsTgsB6Pg}}</div>
|
* Videofluoroscopy shows [[mucosal]] and [[submucosal]] foldings
 
|
Triad of
* [[Iron deficiency anemia]]
* [[Esophageal webs]]
* [[Glossitis]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Esophageal stricture]]
|
* Gradual
 
* Sudden onset
| +
| -
|Progressive
| +/-
| +/-
|
* [[Odynophagia]]
* [[Cough]]
 
* [[Chest pain]]
|Normal
|
*Sacculations
*Fixed transverse folds
*[[Esophageal]] intramural pseudodiverticula   
[[Image:Benign-oesophageal-stricture.jpg|center|200px|thumb|Case courtesy of Dr Ahmed Abd Rabou, Radiopaedia.org, rID: 23008]]
|
* [[Mucosal]] edema
* Circumferential thickening in [[Gastroesophageal reflux disease|GERD]]
* Pale [[mucosa]] with white [[exudate]] in lymphocytic esophagitis
* [[Swelling]] and [[hemorrhagic]] [[congestion]] in [[caustic]]<nowiki/> ingestion
<div style="width:350px">{{#ev:youtube|vax5E-jMnQ}}</div>
|
* [[Manometry]] may show dysmotility
* [[CT scan]] for staging [[malignant]] [[strictures]]
|
* [[Esophagogram|Barium esophagogram]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Diffuse esophageal spasm]]
|
* Sudden
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|Non progressive
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|
* [[Chest pain]]
 
|Normal
|
* Nonperistaltic and nonpropulsive contractions
* Corkscrew or rosary bead esophagus
[[Image:DES radio.png|center|200px|thumb|Barium swallow appearance of DES<br>Source:By Nevit Dilmen [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]]
|
* Inconclusive
<div style="width:350px">{{#ev:youtube|2ipA34iMA3c}}</div>
|
*[[Manometry]] shows high-amplitude [[esophageal]] contractions
*[[CT scan]] may show [[hypertrophy]] of esophageal muscles
|
* [[Manometry]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Achalasia]]
|
* Gradual
| +
|<nowiki>+</nowiki>
|Non progressive
| +/-
| -
|
* [[Regurgitation]] of undigested food
* [[Chest pain]]
|Normal
|
* "Bird's beak" or "rat tail" appearance
* Dilated esophageal body
* Air fluid level (absent [[peristalsis]])
* Absence of an intragastric air bubble
[[Image:Achalasia-2.jpg|center|200px|thumb|Case courtesy of Dr Mario Umana, Radiopaedia.org, rID: 38071]]
|
* Dilated [[esophagus]]
* Residual food fragments
* Normal [[mucosa]]
<div style="width:350px">{{#ev:youtube|ydLcskQzEjM}}</div>
|
* Residual pressure of [[Lower esophageal sphincter|LES]] > 10 mmHg
* Incomplete relaxation of the [[Lower esophageal sphincter|LES]]
* Increased resting tone of [[Lower esophageal sphincter|LES]]
* Aperistalsis
|
* History of [[dysphagia]] with positive [[endoscopy]] and [[manometry]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Systemic sclerosis]]
|
* Gradual
| +
|<nowiki>+</nowiki>
|Progressive
| +/-
| +
|
* [[Muscle pain|Muscle]] and [[Arthralgia|joint pain]]
 
* [[Raynaud's phenomenon]]
 
* [[Skin changes]]
|Normal
|
* Dysmotility
 
* Patulous [[esophagus]]
|
* [[Mucosal]] damage
 
* [[Peptic]] stricture (advanced cases)
|Positive serology for
* [[Antinuclear antibodies]]
 
* [[Rheumatoid factor]]
 
* [[Creatine kinase]]
 
* [[ESR]]
|
* [[Skin biopsy]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Zenker's diverticulum]]
|
* Gradual
| +
|<nowiki>-</nowiki>
|
| +/-
| -
|
* Food [[regurgitation]]
 
* [[Halitosis]]
 
* [[Coughing|Cough]]
 
* [[Hoarseness]]
|Normal
|
* Thin projections on [[esophageal]] wall over [[Killian's dehiscence|Killian's triangle]]
[[Image:Zenker-4.jpg|center|200px|thumb| Radiopaedia.org">{{cite web |url=https://radiopaedia.org/cases/zenker-diverticulum |title=Zenker diverticulum &#124; Radiology Case &#124; Radiopaedia.org |format= |work= |accessdate=}}<nowiki></ref></nowiki>]]
|
* Outpouching of posterior [[pharyngeal]] wall
 
* Exclude the presence of [[Squamous cell carcinoma|SCC]]
<div style="width:350px">{{#ev:youtube|FdEruFsNdVA}}</div> 
|
* [[CT]] & [[MRI]] shows out-pouching over the posterior esophagus in the Killian's triangle
|
* Barium [[Esophagogram|esophagography]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Esophageal carcinoma]]
|
* Gradual
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|Progressive
| +
|<nowiki>+/-</nowiki>
|
* [[Lymphadenopathy]]
 
* [[Cachexia]]
|Normal
|
* Irregular [[Strictures|stricture]]
* Pre-stricture [[dilatation]]
[[Image:Oesophageal-squamous-cell-carcinoma-2.jpg|center|200px|thumb|Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 4232f]]
|
* [[Esophageal]] obstruction
* Staging of disease
<div style="width:350px">{{#ev:youtube|5ucSlgqGAno}}</div>
|
* [[CT]] and [[PET scan]] is an optional test for staging of the disease
|
* [[Biopsy]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Stroke]]
([[Cerebral hemorrhage]])
|
* Sudden
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|Progressive
|<nowiki>+</nowiki>
|<nowiki>+/-</nowiki>
|
* [[Dysarthria]]
 
* Limb [[weakness]]
 
* [[Fatigue]]
|Impaired
|
* Pooling of [[Contrast medium|contrast]] in the [[pharynx]]
* [[Aspiration]] of [[barium]] [[Contrast medium|contrast]] into the [[airway]]
|
* Reduced opening of [[upper esophageal sphincter]]
* Reduced [[larynx]] elevation
|
* [[CT]] without [[contrast]] shows acute [[hemorrhage]] as a hyperattenuating [[clot]]
|
* [[CT]] without [[Contrast medium|contrast]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Motor disorders
([[Myasthenia gravis]])
|
* Gradual
| +
| +
|Progressive
|<nowiki>+/-</nowiki>
|
|
* [[Ptosis]]
* [[Diplopia]]
* [[Fatigue]]
|Normal
|
* Stasis in [[pharynx]] and pooling in pharyngeal recesses
|
* [[Velopharyngeal insufficiency]]
* Delayed [[swallowing]] function
|
* CT may show anterior [[mediastinal]] mass ([[thymoma]])
* Positive tensilon test
|
* Anti–acetylcholine receptor antibody test
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[GERD]]
|
* Gradual
 
* Sudden onset
| +
| -
|Progressive
| +/-
| +
|
* [[Cough]]
 
* [[Hoarseness]]
|Normal
|
* Free acid reflux
* [[Esophagitis]] with scarring
* [[Strictures]]
* [[Barrett's oesophagus]]
|
* [[Erythema]], erosions and [[ulceration]]
* [[Barrett's esophagus]]
|
* Esophageal [[manometry]] may show decreased tone of [[Lower esophageal sphincter|LES]]
|
* 24 hour [[esophageal]] pH monitoring
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Esophageal web]]
|
* Gradual
| +
| +/-
|Progressive
| -
| +/-
|
* Findings of the underlying cause such as [[iron deficiency anemia]] or [[bullous pemphigoid]]
|Normal
|
* Symmetrical narrowing of the [[esophagus]]
|
* Smooth membrane not encircling the whole [[Lumen (anatomy)|lumen]]
|
* Videofluoroscopy shows [[mucosal]] and [[submucosal]] foldings
|
* Barium [[esophagogram]]
|}
<small>


{| class="wikitable"
{| class="wikitable"
Line 16: Line 349:
|Achalasia
|Achalasia
|
|
* Dyspnea<ref>{{cite book | last = Ferri | first = Fred | title = Ferri's clinical advisor 2015 : 5 books in 1 | publisher = Elsevier/Mosby | location = Philadelphia, PA | year = 2015 | isbn = 978-0323083751 }}</ref>
* [[Dyspnea]]<ref>{{cite book | last = Ferri | first = Fred | title = Ferri's clinical advisor 2015 : 5 books in 1 | publisher = Elsevier/Mosby | location = Philadelphia, PA | year = 2015 | isbn = 978-0323083751 }}</ref>


*[[Dysphagia]] for solids and liquids is the most common feature, being seen in 91 % and 85% of patients respectively<ref name="pmid23871090">{{cite journal| author=Boeckxstaens GE, Zaninotto G, Richter JE| title=Achalasia. | journal=Lancet | year= 2013 | volume=  | issue=  | pages=  | pmid=23871090 | doi=10.1016/S0140-6736(13)60651-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23871090  }}</ref>
*[[Dysphagia]] for solids and liquids is the most common feature, being seen in 91 % and 85% of patients respectively<ref name="pmid23871090">{{cite journal| author=Boeckxstaens GE, Zaninotto G, Richter JE| title=Achalasia. | journal=Lancet | year= 2013 | volume=  | issue=  | pages=  | pmid=23871090 | doi=10.1016/S0140-6736(13)60651-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23871090  }}</ref>
Line 22: Line 355:
*[[Cough]] mainly when lying down in 30%<ref name="pmid23871090">{{cite journal| author=Boeckxstaens GE, Zaninotto G, Richter JE| title=Achalasia. | journal=Lancet | year= 2013 | volume=  | issue=  | pages=  | pmid=23871090 | doi=10.1016/S0140-6736(13)60651-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23871090  }} </ref>
*[[Cough]] mainly when lying down in 30%<ref name="pmid23871090">{{cite journal| author=Boeckxstaens GE, Zaninotto G, Richter JE| title=Achalasia. | journal=Lancet | year= 2013 | volume=  | issue=  | pages=  | pmid=23871090 | doi=10.1016/S0140-6736(13)60651-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23871090  }} </ref>
|
|
* Esophagogastroduodenoscopy findings include a dilated esophagus with residual food fragments, normal mucosa and occasionally [[candidiasis]] (due to the prolonged stasis).
* [[Endoscopy|Esophagogastroduodenoscopy]] findings include a dilated esophagus with residual food fragments, normal [[mucosa]] and occasionally [[candidiasis]] (due to the prolonged [[stasis]]).
* Barium swallow shows the characteristic bird's beak appearance.
* [[Barium]] swallow shows the characteristic bird's beak appearance.
[[Image:Acha.jpg|center|300px|thumb|Barium swallow showing bird's beak appearance - By Farnoosh Farrokhi, Michael F. Vaezi. - Idiopathic (primary) achalasia. Orphanet Journal of Rare Diseases 2007, 2:38(http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2040141), CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=2950922]]
[[Image:Acha.jpg|center|300px|thumb|Barium swallow showing bird's beak appearance - By Farnoosh Farrokhi, Michael F. Vaezi. - Idiopathic (primary) achalasia. Orphanet Journal of Rare Diseases 2007, 2:38(http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2040141), CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=2950922]]
|-
|-
|[[GERD]]
|[[GERD]]
|
|
* Retrosternal burning chest pain.
* Retrosternal burning [[chest pain]].
* Cough and hoarseness of voice.
* [[Cough]] and [[Hoarseness|hoarseness of voice]].
* May present with complications such as strictures and dysphagia.<ref name="pmid25133039">{{cite journal |vauthors=Badillo R, Francis D |title=Diagnosis and treatment of gastroesophageal reflux disease |journal=World J Gastrointest Pharmacol Ther |volume=5 |issue=3 |pages=105–12 |year=2014 |pmid=25133039 |pmc=4133436 |doi=10.4292/wjgpt.v5.i3.105 |url=}}</ref>
* May present with complications such as [[strictures]] and [[dysphagia]].<ref name="pmid25133039">{{cite journal |vauthors=Badillo R, Francis D |title=Diagnosis and treatment of gastroesophageal reflux disease |journal=World J Gastrointest Pharmacol Ther |volume=5 |issue=3 |pages=105–12 |year=2014 |pmid=25133039 |pmc=4133436 |doi=10.4292/wjgpt.v5.i3.105 |url=}}</ref>
|
|
* Upper GI endoscopy shows the complications such as esophagitis and barret esophagus.
* [[Endoscopy|Upper GI endoscopy]] shows the complications such as [[esophagitis]] and [[Barrett's esophagus]].
* Esophageal manometry may show decreased tone of the lower esophageal sphincter.
* [[Manometry|Esophageal manometry]] may show decreased tone of the [[lower esophageal sphincter]].
* 24-hour esophageal pH monitoring may be done to confirm the diagnosis.
* 24-hour esophageal pH monitoring may be done to confirm the diagnosis.
[[Image:Barretts esophagus.jpg|center|300px|thumb|Barret's esophagus - By Samir धर्म - taken from patient with permission to place in public domain, Copyrighted free use, https://commons.wikimedia.org/w/index.php?curid=1595945]]
[[Image:Barretts esophagus.jpg|center|300px|thumb|Barret's esophagus - By Samir धर्म - taken from patient with permission to place in public domain, Copyrighted free use, https://commons.wikimedia.org/w/index.php?curid=1595945]]
Line 45: Line 378:
*[[Nausea]] and [[vomiting]]<ref name="pmid24834141">{{cite journal |vauthors=Napier KJ, Scheerer M, Misra S |title=Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities |journal=World J Gastrointest Oncol |volume=6 |issue=5 |pages=112–20 |year=2014 |pmid=24834141 |pmc=4021327 |doi=10.4251/wjgo.v6.i5.112 |url=}}</ref>
*[[Nausea]] and [[vomiting]]<ref name="pmid24834141">{{cite journal |vauthors=Napier KJ, Scheerer M, Misra S |title=Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities |journal=World J Gastrointest Oncol |volume=6 |issue=5 |pages=112–20 |year=2014 |pmid=24834141 |pmc=4021327 |doi=10.4251/wjgo.v6.i5.112 |url=}}</ref>
|
|
* Upper GI endoscopy and esophageal biopsy the gold standard for the diagnosis of esophageal
* [[Endoscopy|Upper GI endoscopy]] and esophageal biopsy the gold standard for the diagnosis of esophageal
[[Image:Esophageal adenoca.jpg|center|300px|thumb|CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=2587715]]
[[Image:Esophageal adenoca.jpg|center|300px|thumb|CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=2587715]]
|-
|-
|[[Esophageal spasm|Corckscrew esophagus]]
|[[Esophageal spasm|Corckscrew esophagus]]
|
|
*Retrosternal chest pain that presents with or without food intake.<ref name="pmid28943381">{{cite journal |vauthors=Matsuura H |title=Diffuse Esophageal Spasm: Corkscrew Esophagus |journal=Am. J. Med. |volume= |issue= |pages= |year=2017 |pmid=28943381 |doi=10.1016/j.amjmed.2017.08.041 |url=}}</ref>
*[[Chest pain|Retrosternal chest pain]] that presents with or without food intake.<ref name="pmid28943381">{{cite journal |vauthors=Matsuura H |title=Diffuse Esophageal Spasm: Corkscrew Esophagus |journal=Am. J. Med. |volume= |issue= |pages= |year=2017 |pmid=28943381 |doi=10.1016/j.amjmed.2017.08.041 |url=}}</ref>
*The condition is not progressive and not causing complications.<ref name="pmid1736462">{{cite journal |vauthors=Lassen JF, Jensen TM |title=[Corkscrew esophagus] |language=Danish |journal=Ugeskr. Laeg. |volume=154 |issue=5 |pages=277–80 |year=1992 |pmid=1736462 |doi= |url=}}</ref>
*The condition is not progressive and not causing complications.<ref name="pmid1736462">{{cite journal |vauthors=Lassen JF, Jensen TM |title=[Corkscrew esophagus] |language=Danish |journal=Ugeskr. Laeg. |volume=154 |issue=5 |pages=277–80 |year=1992 |pmid=1736462 |doi= |url=}}</ref>
|
|
* Barium swallow shows the characteristic corckscrew appearance of the esophagus.
* [[Barium swallow]] shows the characteristic corckscrew appearance of the esophagus.
[[Image:Nutcracker-esophagus-004.jpg|center|300px|thumb|Corckscrew esophagus - Case courtesy of Radswiki, Radiopaedia.org, rID: 11680]]
[[Image:Nutcracker-esophagus-004.jpg|center|300px|thumb|Corckscrew esophagus - Case courtesy of Radswiki, Radiopaedia.org, rID: 11680]]
|-
|-
|[[Esophageal stricture]]
|[[Esophageal stricture]]
|
|
*Patient may present with the symptoms of the underlying GERD.
*Patient may present with the symptoms of the underlying [[GERD]].
*Dysphagia and odynophagia.<ref name="pmid17227515">{{cite journal |vauthors=Ruigómez A, García Rodríguez LA, Wallander MA, Johansson S, Eklund S |title=Esophageal stricture: incidence, treatment patterns, and recurrence rate |journal=Am. J. Gastroenterol. |volume=101 |issue=12 |pages=2685–92 |year=2006 |pmid=17227515 |doi=10.1111/j.1572-0241.2006.00828.x |url=}}</ref>
*[[Dysphagia]] and [[odynophagia]].<ref name="pmid17227515">{{cite journal |vauthors=Ruigómez A, García Rodríguez LA, Wallander MA, Johansson S, Eklund S |title=Esophageal stricture: incidence, treatment patterns, and recurrence rate |journal=Am. J. Gastroenterol. |volume=101 |issue=12 |pages=2685–92 |year=2006 |pmid=17227515 |doi=10.1111/j.1572-0241.2006.00828.x |url=}}</ref>
|
|
* Barium esophagography provides information about the site and the diameter of the stricture before the endoscopic intervention.<ref name="pmid25013392">{{cite journal |vauthors=Shami VM |title=Endoscopic management of esophageal strictures |journal=Gastroenterol Hepatol (N Y) |volume=10 |issue=6 |pages=389–91 |year=2014 |pmid=25013392 |pmc=4080876 |doi= |url=}}</ref>
* [[Barium swallow|Barium esophagography]] provides information about the site and the diameter of the stricture before the [[Endoscopy|endoscopic intervention]].<ref name="pmid25013392">{{cite journal |vauthors=Shami VM |title=Endoscopic management of esophageal strictures |journal=Gastroenterol Hepatol (N Y) |volume=10 |issue=6 |pages=389–91 |year=2014 |pmid=25013392 |pmc=4080876 |doi= |url=}}</ref>
[[Image:Peptic stricture.png|center|300px|thumb|Peptic stricture - By Samir धर्म - From en.wikipedia.org, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1931423]]
[[Image:Peptic stricture.png|center|300px|thumb|Peptic stricture - By Samir धर्म - From en.wikipedia.org, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1931423]]
|-
|-
|Plummer-Vinson syndrome
|[[Plummer-Vinson syndrome]]
|Common symptoms of  Plummer-Vinson syndrome include:<ref name="pmid11753173">{{cite journal |vauthors=López Rodríguez MJ, Robledo Andrés P, Amarilla Jiménez A, Roncero Maíllo M, López Lafuente A, Arroyo Carrera I |title=Sideropenic dysphagia in an adolescent |journal=J. Pediatr. Gastroenterol. Nutr. |volume=34 |issue=1 |pages=87–90 |year=2002 |pmid=11753173 |doi= |url=}}</ref><ref name="pmid4449772">{{cite journal |vauthors=Chisholm M |title=The association between webs, iron and post-cricoid carcinoma |journal=Postgrad Med J |volume=50 |issue=582 |pages=215–9 |year=1974 |pmid=4449772 |pmc=2495558 |doi= |url=}}</ref><ref name="pmid1192404">{{cite journal |vauthors=Larsson LG, Sandström A, Westling P |title=Relationship of Plummer-Vinson disease to cancer of the upper alimentary tract in Sweden |journal=Cancer Res. |volume=35 |issue=11 Pt. 2 |pages=3308–16 |year=1975 |pmid=1192404 |doi= |url=}}</ref>
|Common symptoms of  [[Plummer-Vinson syndrome]] include<ref name="pmid11753173">{{cite journal |vauthors=López Rodríguez MJ, Robledo Andrés P, Amarilla Jiménez A, Roncero Maíllo M, López Lafuente A, Arroyo Carrera I |title=Sideropenic dysphagia in an adolescent |journal=J. Pediatr. Gastroenterol. Nutr. |volume=34 |issue=1 |pages=87–90 |year=2002 |pmid=11753173 |doi= |url=}}</ref><ref name="pmid4449772">{{cite journal |vauthors=Chisholm M |title=The association between webs, iron and post-cricoid carcinoma |journal=Postgrad Med J |volume=50 |issue=582 |pages=215–9 |year=1974 |pmid=4449772 |pmc=2495558 |doi= |url=}}</ref><ref name="pmid1192404">{{cite journal |vauthors=Larsson LG, Sandström A, Westling P |title=Relationship of Plummer-Vinson disease to cancer of the upper alimentary tract in Sweden |journal=Cancer Res. |volume=35 |issue=11 Pt. 2 |pages=3308–16 |year=1975 |pmid=1192404 |doi= |url=}}</ref>
*Difficulty swallowing (more for solids)
*Difficulty swallowing (more for solids)
*[[Weakness]]
*[[Weakness]]
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*Painful cracks in the angles of a dry mouth
*Painful cracks in the angles of a dry mouth
*Pale color of the skin
*Pale color of the skin
===Less cmmon symptoms===
Less cmmon symptoms
*Cold intolerance
*Cold intolerance
*Reduced resistance to infection
*Reduced resistance to infection
*Altered behavior
*Altered behavior
*Craving for for unusual items (such as ice or cold vegetables)
*Craving for for unusual items (such as ice or cold vegetables)
|Lab tests are consistent with the diagnosis of iron deficiency anemia.
|
 
* Lab tests are consistent with the diagnosis of [[iron deficiency anemia]].
Findings on an [[x-ray]] ([[barium]] [[esophagogram]]) suggestive of [[esophageal web]]/[[strictures]] associated with Plummer-Vinson syndrome appear as either:
* Findings on an [[x-ray]] ([[barium]] [[esophagogram]]) suggestive of [[esophageal web]]/[[strictures]] associated with [[Plummer-Vinson syndrome]] appear as either:
* Thin projections on the anterior [[esophageal]] wall.
:* Thin projections on the anterior [[esophageal]] wall.
* Multiple upper ([[cervical]]) [[Esophageal stricture|esophageal constrictions]] consistent with [[esophageal webs]].
:* Multiple upper ([[cervical]]) [[Esophageal stricture|esophageal constrictions]] consistent with [[esophageal webs]].


[[Image:Plummer-vinson-syndrome.jpg|center|200px|thumb|Plummer-Vinson syndrome (Source: Case courtesy of Dr Hani Salam, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/14029">rID: 14029</a>)]]
[[Image:Plummer-vinson-syndrome.jpg|center|200px|thumb|Plummer-Vinson syndrome (Source: Case courtesy of Dr Hani Salam, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/14029">rID: 14029</a>)]]
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[[Category:Gastroenterology]]
[[Category:Gastroenterology]]
[[Category:Otolaryngology]]
[[Category:Otolaryngology]]
[[Category:Differential diagnosis]]


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Latest revision as of 01:58, 24 August 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Overview

Achalasia must be differentiated from other causes of dysphagia, odynophagia and food regurgitation such as GERD, esophageal adenocarcinoma, esophageal stricture, esophageal webs, motor disorders such as myasthenia gravis, stroke, Zenker's diverticulum, diffuse esophageal spasm, systemic sclerosis and Plummer Vinson syndrome.

Differentiating Achlasia from other Disease

Achalasia must be differentiated from other causes of dysphagia, odynophagia and food regurgitation such as GERD, esophageal adenocarcinoma and esophageal stricture.

Disease Signs and Symptoms Barium esophagogram Endoscopy Other imaging and laboratory findings Gold Standard
Onset Dysphagia Weight loss Heartburn Other findings Mental status
Solids Liquids Type
Plummer-Vinson syndrome
  • Gradual
+ - Non progressive +/- - Normal
Barium esophagogram (Source: Case courtesy of Dr Hani Salam, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/14029">rID: 14029</a>)
{{#ev:youtube|HFfsTgsB6Pg}}

Triad of

Esophageal stricture
  • Gradual
  • Sudden onset
+ - Progressive +/- +/- Normal
  • Sacculations
  • Fixed transverse folds
  • Esophageal intramural pseudodiverticula   
Case courtesy of Dr Ahmed Abd Rabou, Radiopaedia.org, rID: 23008
{{#ev:youtube|vax5E-jMnQ}}
Diffuse esophageal spasm
  • Sudden
+ + Non progressive + + Normal
  • Nonperistaltic and nonpropulsive contractions
  • Corkscrew or rosary bead esophagus
Barium swallow appearance of DES
Source:By Nevit Dilmen [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)
  • Inconclusive
{{#ev:youtube|2ipA34iMA3c}}
Achalasia
  • Gradual
+ + Non progressive +/- - Normal
  • "Bird's beak" or "rat tail" appearance
  • Dilated esophageal body
  • Air fluid level (absent peristalsis)
  • Absence of an intragastric air bubble
Case courtesy of Dr Mario Umana, Radiopaedia.org, rID: 38071
{{#ev:youtube|ydLcskQzEjM}}
  • Residual pressure of LES > 10 mmHg
  • Incomplete relaxation of the LES
  • Increased resting tone of LES
  • Aperistalsis
Systemic sclerosis
  • Gradual
+ + Progressive +/- + Normal
  • Dysmotility
  • Peptic stricture (advanced cases)
Positive serology for
Zenker's diverticulum
  • Gradual
+ - +/- - Normal
Radiopaedia.org">"Zenker diverticulum | Radiology Case | Radiopaedia.org".</ref>
  • Exclude the presence of SCC
{{#ev:youtube|FdEruFsNdVA}}
 
  • CT & MRI shows out-pouching over the posterior esophagus in the Killian's triangle
Esophageal carcinoma
  • Gradual
+ + Progressive + +/- Normal
Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 4232f
{{#ev:youtube|5ucSlgqGAno}}
  • CT and PET scan is an optional test for staging of the disease
Stroke

(Cerebral hemorrhage)

  • Sudden
+ + Progressive + +/- Impaired
Motor disorders

(Myasthenia gravis)

  • Gradual
+ + Progressive +/- Normal
  • Stasis in pharynx and pooling in pharyngeal recesses
  • Anti–acetylcholine receptor antibody test
GERD
  • Gradual
  • Sudden onset
+ - Progressive +/- + Normal
Esophageal web
  • Gradual
+ +/- Progressive - +/- Normal
  • Smooth membrane not encircling the whole lumen

Manifestations Diagnostic tools
Achalasia
  • Dysphagia for solids and liquids is the most common feature, being seen in 91 % and 85% of patients respectively[2]
  • Regurgitation of undigested food occurs in 76-91% of patients[2]
  • Cough mainly when lying down in 30%[2]
Barium swallow showing bird's beak appearance - By Farnoosh Farrokhi, Michael F. Vaezi. - Idiopathic (primary) achalasia. Orphanet Journal of Rare Diseases 2007, 2:38(http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2040141), CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=2950922
GERD
Barret's esophagus - By Samir धर्म - taken from patient with permission to place in public domain, Copyrighted free use, https://commons.wikimedia.org/w/index.php?curid=1595945
Esophageal carcinoma
  • Dysphagia
  • Odynophagia- fluids and soft foods are usually tolerated, while hard or bulky substances (such as bread or meat) cause much more difficulty[4]
  • Weight loss
  • Pain, often of a burning nature, may be severe and worsened by swallowing, and can be spasmodic in character
  • Nausea and vomiting[4]
  • Upper GI endoscopy and esophageal biopsy the gold standard for the diagnosis of esophageal
CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=2587715
Corckscrew esophagus
  • Barium swallow shows the characteristic corckscrew appearance of the esophagus.
Corckscrew esophagus - Case courtesy of Radswiki, Radiopaedia.org, rID: 11680
Esophageal stricture
Peptic stricture - By Samir धर्म - From en.wikipedia.org, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1931423
Plummer-Vinson syndrome Common symptoms of Plummer-Vinson syndrome include[9][10][11]
  • Difficulty swallowing (more for solids)
  • Weakness
  • Pain
  • Burning sensation in mouth
  • Dry tongue
  • Painful cracks in the angles of a dry mouth
  • Pale color of the skin

Less cmmon symptoms

  • Cold intolerance
  • Reduced resistance to infection
  • Altered behavior
  • Craving for for unusual items (such as ice or cold vegetables)
Plummer-Vinson syndrome (Source: Case courtesy of Dr Hani Salam, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/14029">rID: 14029</a>)

References

  1. Ferri, Fred (2015). Ferri's clinical advisor 2015 : 5 books in 1. Philadelphia, PA: Elsevier/Mosby. ISBN 978-0323083751.
  2. 2.0 2.1 2.2 Boeckxstaens GE, Zaninotto G, Richter JE (2013). "Achalasia". Lancet. doi:10.1016/S0140-6736(13)60651-0. PMID 23871090.
  3. Badillo R, Francis D (2014). "Diagnosis and treatment of gastroesophageal reflux disease". World J Gastrointest Pharmacol Ther. 5 (3): 105–12. doi:10.4292/wjgpt.v5.i3.105. PMC 4133436. PMID 25133039.
  4. 4.0 4.1 Napier KJ, Scheerer M, Misra S (2014). "Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities". World J Gastrointest Oncol. 6 (5): 112–20. doi:10.4251/wjgo.v6.i5.112. PMC 4021327. PMID 24834141.
  5. Matsuura H (2017). "Diffuse Esophageal Spasm: Corkscrew Esophagus". Am. J. Med. doi:10.1016/j.amjmed.2017.08.041. PMID 28943381.
  6. Lassen JF, Jensen TM (1992). "[Corkscrew esophagus]". Ugeskr. Laeg. (in Danish). 154 (5): 277–80. PMID 1736462.
  7. Ruigómez A, García Rodríguez LA, Wallander MA, Johansson S, Eklund S (2006). "Esophageal stricture: incidence, treatment patterns, and recurrence rate". Am. J. Gastroenterol. 101 (12): 2685–92. doi:10.1111/j.1572-0241.2006.00828.x. PMID 17227515.
  8. Shami VM (2014). "Endoscopic management of esophageal strictures". Gastroenterol Hepatol (N Y). 10 (6): 389–91. PMC 4080876. PMID 25013392.
  9. López Rodríguez MJ, Robledo Andrés P, Amarilla Jiménez A, Roncero Maíllo M, López Lafuente A, Arroyo Carrera I (2002). "Sideropenic dysphagia in an adolescent". J. Pediatr. Gastroenterol. Nutr. 34 (1): 87–90. PMID 11753173.
  10. Chisholm M (1974). "The association between webs, iron and post-cricoid carcinoma". Postgrad Med J. 50 (582): 215–9. PMC 2495558. PMID 4449772.
  11. Larsson LG, Sandström A, Westling P (1975). "Relationship of Plummer-Vinson disease to cancer of the upper alimentary tract in Sweden". Cancer Res. 35 (11 Pt. 2): 3308–16. PMID 1192404.


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