Esophageal Motility Disorders Differential Diagnoses

Updated: Dec 29, 2017
  • Author: Eric A Gaumnitz, MD; Chief Editor: Praveen K Roy, MD, MSc  more...
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Diagnostic Considerations

As with all reported symptoms, the differential diagnosis depends on presenting symptoms. With complaints of chest pain, coronary artery disease is the major concern and should be evaluated prior to an esophageal workup for esophageal motility disorders. Prolonged, nonexertional chest pain that is meal-related and relieved with antacids favors an esophageal etiology for chest pain. Heartburn and regurgitation further suggest esophageal etiology of chest pain with a component of reflux disease, whether it is related to esophageal dysmotility or complicating scleroderma.

In patients with dysphagia, mechanical obstructing lesions, benign or malignant, must be ruled out with esophageal endoscopic or radiographic imaging studies.

When considering a diagnosis of achalasia, the differential diagnosis includes Chagas disease secondary to Trypanosoma cruzi infection and pseudoachalasia from gastroesophageal junction tumors. An early form of achalasia, known as vigorous achalasia, can be confused with diffuse esophageal spasm.

Chagas disease

Chagas disease is an infectious disease with esophageal functioning that mimics achalasia. This condition is caused by the protozoan T cruzi, which is transmitted by a reduviid (kissing) bug bite. Chagas disease is endemic in South and Central America but has been discovered as far north as Texas. The initial manifestation is septicemia, ranging from clinically silent to life threatening; a chronic stage may then ensue. Pathophysiology reveals widespread ganglionic destruction throughout the body, involving the heart, gut, urinary tract, and respiratory tract. Clinically significant disease takes years to develop.

The most common cause of death is cardiac involvement with cardiomyopathy, conduction disturbances, and arrhythmias. Gastrointestinal tract involvement includes megaesophagus, megacolon, and megaduodenum. Esophageal involvement starts with atonic esophageal body and a nonrelaxing LES, subsequently leading to esophageal dilation. The diagnosis is confirmed by serologic testing.

Treatment of patients with esophageal Chagas disease is similar to the treatment of patients with idiopathic achalasia. Treatment is geared toward disrupting the LES. Once esophageal nerve loss has occurred, regrowth or replacement of this nerve loss is not possible. For patients with acute infection, treatment with nifurtimox and benznidazole has shown limited efficacy and has no proven efficacy in patients with chronic infection.

Familial adrenal insufficiency with alacrima

Familial adrenal insufficiency with alacrima is an autosomal recessive childhood disease with autonomic nervous system dysfunction. This condition progresses to a picture of achalasia, alacrima, sinoatrial dysfunction, and delayed gastric emptying.


Pseudoachalasia is a term used to describe the clinical picture of gastroesophageal junction obstruction, most classically by tumor. This condition is present in as many as 5% of patients with the manometric and radiologic diagnosis of achalasia. This clinical presentation is more likely to occur with rapidly progressive disease (< 1 y), older age of onset (>50 y), and profound weight loss. Tumor infiltration, especially involving the gastric fundus, mimics the functional impairment observed with idiopathic achalasia.

A thorough workup for achalasia includes an upper endoscopy. Biopsies should be obtained with any suspicion of a malignant process. If a suspicious lesion is found, imaging studies, including CT scan, MRI, and endoscopic ultrasound, should be obtained as indicated. In 50% of patients, the pathology is adenocarcinoma of the gastroesophageal junction. Other causes for pseudoachalasia include other malignancies, mechanical obstruction (eg, neurofibromatosis, pancreatic pseudocyst), and infiltrative diseases (eg, amyloidosis, sphingolipids, eosinophilic gastritis, sarcoidosis).

Diffuse esophageal spasm

DES and vigorous achalasia can be confused, as both have the common feature of active, higher amplitude simultaneous contractions of the esophagus. Manometric criteria require that some normal esophageal peristalsis must be present intermittently for DES. In addition, LES relaxation, which commonly is incomplete in patients with achalasia, should be normal in patients with DES. This issue is further complicated in that DES may evolve into achalasia with time, so a continuum with progression to aperistalsis is likely.

Differential Diagnoses