General data
M.S is 70 year old male , single , muslim,construction worker
History of present illness
6 month PTC, patient noted difficulty in swallowing of food
described as food being stuck in his throat ,which is relieved by
drinking of water together with the food to facilitate swallowing.
Approximately 1 month PTC, patient noted worsening of symptoms
now associated with vomiting of undigested food and saliva.
History
Past Medical History
Hypertension for 20 years
Diabetes Mellitus Type 2 for 20 years
Family History
Maternal Side: Hypertension,Diabetes Mellitus
Paternal Side: Hypertension
Personal and Social History
Non smoker
Occassional Alchoholic Beverage drinker
Pescatarian.
Physical Examination
Vital signs
• BP: 140/80
• HR 65
• RR: 22
• Temp: 36.5
• Weight: 60Kg
• Height: 5’4”
Salient Features
Awake, conscious, cooperative, oriented, not in respiratory distress
Skin : good skin turgor, fair,
HEENT : sunken eyeballs, non-icteric sclerae, pupils equal reactive to Light
dry lips and tongue.
Neck : no masses, no palpable lymph nodes
Chest : symmetrical, equal chest expansion, clear breath sounds
Salient Features
CVS : regular rate and rhythm, no murmurs
Abdomen : flat, normoactive bowel sounds, tympanitic, no tenderness, no
palpable masses.
Genitourinary tract system : - KPS
Extremities : All extremities have Full rom, full and equal pulses on all
Extremities.
Primary Impression
The initial impression based on PE and pertinent findings would be
Zenkers diverticulum based on
Dysphagia - primary symptom
patient's discription as "food being stuck in his throat"
Chokes or vomit with eating
Requires liquid with the meal
Prolonged dysphagia
Elderly white male
Differential
Rule In Rule Out
diagnosis
Dysphagia ,for both solids and liquids as Not yet clarified need diagnostic
Achalasia they lack esophageal peristalsis. test
No signs of heartburn or
GERD Difficulty swallowing regurgitation seen , need
endoscopy and pH monitoring
Esophageal Endoscopy for further
Dysphagia , fair skin , age, vomiting
confirmation
cancer
DIAGNOSTICS
Barium Swallow (Esophagram):
Visualizes the esophagus to identify structural issues like strictures or
tumors
Upper Endoscopy ( EGD):
Directly examines the esophagus, stomach, and duodenum for
abnormalities; allows for biopsies.
Esophageal Manometry:
Measures esophageal muscle contractions to diagnose motility
disorders.
24-hour pH Monitoring:
Assesses acid reflux, which can cause dysphagia and vomiting.
Complete Blood Count (CBC):
Checks for anemia or infection.
Blood Glucose and HbA1c Levels:
Evaluates glucose control due to the patient’s diabetes history.
Chest X-ray:
Rules out mediastinal masses or lung issues.
Nutritional Assessment:
Evaluates nutritional status to address potential malnutrition from
chronic dysphagia and vomiting.
Interpretation of results
Barium swallow
Dilated esophagus
narrowing at LES
barium stasis
"Bird-Beak" appearance
Delayed retention
EGD a, Functional stenosis
b, wrapping around the junction
c, Abnormal contractions
d, Mucosal thickening
e dilation of esophageal lumen
f,g, liquid and/or food remnants
Manometry
Significant reductions or absence
of peristaltic wave activity in the
esophagus
Elevated LES resting pressure
Final Impression
Based on history, physical examination and diagnostic
test ( Endoscopy and Manometry) , the final diagnosis
is Type I Classic Achalasia.
• Absence of peristalsis.
• Minimal or no esophageal pressurization.
• Most severe form with the least esophageal contraction.
TREATMENT
1. Pneumatic dilation
2. Calcium channel blockers
3. Injection botulinum toxin-endoscopically
4. Laparoscopic Heller myotomy
Post op Barium swallow test
Improved clearance
Improved relaxation of LES
Complications in Achalasia
1. Esophageal dilation: Over time, the esophagus can become
dilated (enlarged) due to the inability of food and liquids to pass
properly.
2. Aspiration pneumonia: Food or liquids may be regurgitated and
inhaled into the lungs, causing pneumonia.
Complications in Achalasia
3. Esophagitis: Inflammation of the esophagus due to food sitting
in the esophagus for long periods.
4. Weight loss and malnutrition: Difficulty swallowing can lead to
reduced food intake, resulting in weight loss and poor nutrition.
Complications in Achalasia
5. Increased risk of esophageal cancer: Long-term achalasia can
slightly increase the risk of developing esophageal cancer,
particularly squamous cell carcinoma.
Anatomy and Pathophysiology
Location
Extends from the
pharyngoesophageal sphincter
C6 to cardia of stomach
Anatomy and Pathophysiology
Portion
- Cervical portion: 5cm long from C6 to
T1-2 (inferior thyroid artery)
- Thoracic portion- 20cm long extends
from the thoracic inlet to diaphragm
(bronchial arteries)
- Abdominal portion- 2cm long extendes
from diaphragm to cardia of stomach
(ascending branch of the Lt. gastric
artery & inferior phrenic arteries)
Anatomy and Pathophysiology
Narrowing
Anatomy and Pathophysiology
Phases of Swallowing
Swallowing Mechanism
1. Oral Phase: Tongue pushes
bolus to the oropharynx.
2. Pharyngeal Phase: Reflexive
action lasting ~1.5 seconds;
involves soft palate and
larynx elevation.
3. Esophageal Phase: UES
relaxes; peristaltic
contractions move the bolus
to the stomach.
Anatomy and Pathophysiology
Motility disorder
Achalasia:
Failure of the LES to relax
properly, leading to
dysphagia (difficulty
swallowing), regurgitation,
and chest pain.
Physiologic Reflux:
Physiologic Reflux: Occurs more frequently when awake and upright due to
transient losses of the gastroesophageal barrier and higher intra-abdominal
pressure.
Pressure Gradient: A 12-mmHg pressure gradient exists between intra-
abdominal and intrathoracic pressures when upright, promoting reflux.
Lower Esophageal Sphincter (LES) Pressure: LES pressure is higher in the
supine position due to abdominal pressure, reducing reflux risk compared to
the upright position.
Neural and Hormonal Modulation: Various neurotransmitters and hormones
influence LES pressure, affecting reflux occurrence.
Follow up
Regular monitoring
Symptom Management
Nutritional support
Repeat treatment
Long term care
Lifestyle adjustments
Thank You
