eMedicine Specialties > Radiology > Gastrointestinal

Achalasia: Imaging

Author: Michael AJ Sawyer, MD, Consulting Staff, Department of Surgery, Southwestern Medical Center; Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Inc
Coauthor(s): Thomas F Murphy, MD, Chief of Abdominal Imaging Section, Department of Radiology, Tripler Army Medical Center
Contributor Information and Disclosures

Updated: Oct 30, 2009

Radiography

Findings

Plain chest radiographs occasionally offer clues in the diagnosis of achalasia. A double mediastinal stripe is occasionally depicted. An air-fluid level can be seen in the esophagus; this is frequently retrocardiac. Owing to the paucity of air progressing through the hypertensive LES, the gastric air bubble may be small or absent.

Features of achalasia depicted at barium study under fluoroscopic guidance include the following:

  • Failure of peristalsis to clear the esophagus of barium with the patient in the recumbent position
  • Antegrade and retrograde motion of barium in the esophagus secondary to uncoordinated, nonpropulsive, tertiary contractions
  • Pooling or stasis of barium in the esophagus when the esophagus has become atonic or noncontractile (which occurs late in the course of disease)
  • LES relaxation that is incomplete and not coordinated with esophageal contraction
  • Dilation of the esophageal body, which is typically maximal in the distal esophagus
  • Tapering of the barium column at the unrelaxed LES, resulting in the bird beak sign
  • Associated epiphrenic diverticula (possible finding)

According to Schima and coworkers, approximately 90% of patients undergoing barium swallow examination for suspected achalasia have some esophageal dilation and a classic bird beak deformity.17

A study from El-Takli and colleagues contradicts this claim.18 These investigators reviewed the barium-contrast radiographs of 51 patients with manometrically diagnosed achalasia. In only 58% of these studies was achalasia mentioned as a diagnostic possibility by the interpreting radiologist. The radiographs were then provided to an expert gastrointestinal radiologist, mixed in with normal control studies. This expert determined that typical radiologic features of achalasia were absent in 50% of the studies performed on achalasia patients. The authors concluded that barium-contrast radiography is not sensitive for the diagnosis of achalasia, frequently due to the lack of characteristic and detectable radiologic features.

Kostic and coinvestigators published preliminary data on timed barium esophagograms in patients with achalasia and in normal controls.19 Subjects were fasted and then given 250 mL of low-density barium sulfate suspension orally. Radiographs were made 1, 2, and 5 minutes after the start of barium administration. The height and width of the barium column and the rate of change over time were recorded. The study was repeated in all subjects after an approximate 1-week interval. The controls uniformly achieved complete esophageal emptying within 2 minutes. The height and width of the barium column and the rate of esophageal emptying were all markedly abnormal in the achalasia patients. The static data were very reproducible between studies, but the functional (esophageal emptying) data were not, with a coefficient of correlation of only 0.50. The authors concluded that further studies were necessary before clinical usefulness of the timed barium esophagograms could be confirmed.

Degree of Confidence

Chest radiographic findings have low sensitivity and specificity for the diagnosis of achalasia. If suspected, achalasia should be confirmed with other radiologic examinations, such as barium swallow study under fluoroscopy, and with upper gastrointestinal endoscopy and manometry.

False Positives/Negatives

No normal variants exist; however, several disease processes can mimic achalasia on chest radiographs or barium swallow studies. These include colon adenocarcinoma, esophageal carcinoma, gastric carcinoma, non–small cell lung cancer, thoracic scleroderma, amyloidosis, Chagas disease, collagen-vascular disease, and lymphoma.

According to Gockel and colleagues, pseudoachalasia, caused by carcinomas and other disease processes or iatrogenic conditions involving the cardia and gastroesophageal junction, may be difficult to differentiate from achalasia.20 Pseudoachalasia may be indistinguishable from achalasia when conventional endoscopic, manometric, and radiologic diagnostic means are used. In their report, they described that pseudoachalasia was caused by primary malignancies in 53.9%, secondary malignancies in 14.9%, and benign lesions in 12.6% of the 264 cases in the series. The remainder of the cases (11.9%) were due to sequelae of operations involving the distal esophagus or proximal stomach.

Esophageal motor abnormalities can result from tumor infiltration of the esophageal wall and associated nerve damage. If mucosal irregularity or mass effect is present at the tapered gastroesophageal junction, pseudoachalasia should be considered. The use of amyl nitrite can often be helpful, as the LES relaxes in achalasia but remains fixed in pseudoachalasia.

Computed Tomography

Findings

CT scanning with oral contrast enhancement may demonstrate the gross structural esophageal abnormalities associated with achalasia, especially dilatation, which is seen in advanced stages. However, CT findings are nonspecific, and the diagnosis of achalasia cannot be made using CT alone. CT scan may be indicated in the workup of patients with suspected pseudoachalasia.

Degree of Confidence

CT findings are nonspecific and insensitive in the early stages of achalasia. CT findings should always be confirmed by means of barium swallow study with fluoroscopy, upper gastrointestinal endoscopy, and esophageal manometry.

False Positives/Negatives

Disease processes that can mimic achalasia include colon adenocarcinoma, esophageal carcinoma, gastric carcinoma, non–small cell lung cancer, thoracic scleroderma, amyloidosis, Chagas disease, collagen-vascular disease, and lymphoma.

Ultrasonography

Findings

While ultrasound is not useful in establishing the primary diagnosis of achalasia, a recent study investigated its utility as a tool in the differentiation of true achalasia from pseudoachalasia.

Eckardt and coinvestigators performed transabdominal ultrasonography in subjects with achalasia (n = 28), in those with pseudoachalasia (ie, neoplasms of the gastric cardia, n = 13), and in 28 age- and sex-matched controls.21 The images were interpreted by a blinded observer. Achalasia patients could be discriminated from normal controls on the basis of a dilated esophagus without the presence of a neoplastic lesion. The median maximum esophageal diameter in achalasia patients was 20 mm, compared with 10.1 mm in controls (P <.001). Pseudoachalasia appeared as a hypoechoic lesion at the gastric cardia. Sensitivity and specificity rates for the diagnosis of pseudoachalasia were 100% and 82%, respectively.

Mittal reported on the utility of high-frequency intraluminal esophageal ultrasound in various esophageal motor disorders, including achalasia, diffuse esophageal spasm, and nutcracker esophagus.22 Hypertrophy and asynchrony of the longitudinal and circular muscle layers can be identified. Sustained contraction of the longitudinal muscle layer has been shown to correlate with symptoms such as chest pain and heartburn. This technique is not yet prevalent in clinical practice.

Degree of Confidence

Ultrasonography is not recommended for the primary diagnosis of achalasia at this time. As described above, it may prove useful as a screening test to discern achalasia from pseudoachalasia.

More on Achalasia

Overview: Achalasia
Imaging: Achalasia
Follow-up: Achalasia
Multimedia: Achalasia
References
Further Reading
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Keywords

achalasia, esophageal motor disorder, cardiospasm, primary achalasia, secondary achalasia, LES relaxation, lower esophageal sphincter relaxation, failure of LES relaxation, dysphagia, pseudoachalasia, esophageal distention, bird beak deformity, atonic esophagus, primary achalasia, secondary achalasia

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Contributor Information and Disclosures

Author

Michael AJ Sawyer, MD, Consulting Staff, Department of Surgery, Southwestern Medical Center; Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Inc
Michael AJ Sawyer, MD is a member of the following medical societies: American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Thomas F Murphy, MD, Chief of Abdominal Imaging Section, Department of Radiology, Tripler Army Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

David Andrew Nicholson, MBBS, FRCR, Honorary Lecturer, Department of Radiology, University of Manchester; Consultant Gastrointestinal Radiologist, Department of Radiology, Hope Hospital, Salford Royal Hospital NHS Trust, UK
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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