ANSWER 55
The likely diagnosis is achalasia of the cardia, a primary neurological disturbance of the
nerve plexuses at the lower end of the oesophagus. The X-ray shows a dilated fluid-filled
oesophagus with no visible gastric air bubble. Endoscopy may be normal in the early stages
as in this case. The oesophagus has now dilated and there has been spill-over of stagnant food
into the lungs giving her the episodes of repeated respiratory infections. Such aspiration is
most likely to affect the right lower lobe because of the more vertical right main bronchus,
although the result of aspiration at night may depend on the position of the patient. The dys-
phagia is often variable early on. It tends to be present for all foods, indicating a motility
problem, and there may initially be some relief from the mechanical load as the oesophagus
fills. Dysphagia for bulky, solid foods first usually indicates an obstructive lesion.
The diagnosis can be made at this stage by a barium swallow showing the dilated oesopha-
gus. Earlier it may require careful cine-radiology with a bolus of food impregnated with
barium, or oesophageal motility studies using a catheter fitted with a number of pressure
sensors to detect the abnormal motility of the oesophageal muscle.
A similar condition can be produced by the protozoan parasite Trypanosoma cruzi(Chagas’
disease), but this is limited to South and Central America and would not be relevant to her
stay in the north-west United States.
Other common causes of dysphagia are benign oesophageal structures from acid reflux,
malignant structures, external compression or an oesophageal pouch. Achalasia may be
managed by muscle relaxants when mild, but often requires treatment to disrupt the lower
oesophageal muscle by dilatation or surgery.
- The subjective site of blockage in dysphagia may not reflect accurately the level of the
obstruction. - Persistent dysphagia without explanation needs investigation by barium swallow or
endoscopy.