Ease Into Prep with a PANCE^® Question of the Day

The correct answer is A. The clinical and radiologic picture is that of achalasia, which starts with failure of the lower esophageal sphincter to relax. The word "achalasia" in fact means "failure to relax." In addition to having inability of the lower sphincter to relax, patients also have poor tertiary stripping waves (peristalsis) in the esophagus, which causes an inability of the patient to pass the food from the esophagus into the stomach. Because this is a motor disorder, esophageal manometry could also be used to make this diagnosis.

Acid reflux (choice B) patients would have a long history of heartburn and pain leading eventually to stricture. Patients who have acid reflux would have retained food in the esophagus with dysphagia, but this retained food would be the result of a stricture and this would be readily identified on the barium swallow or esophageal manometry studies.

Replacement of smooth muscle by fibrous tissue (choice C) is the pathophysiologic process with scleroderma. Other manifestations of that disease would include induration of the skin, arthralgias, and Raynaud phenomenon.

As noted, the initial problem is failure of the lower esophageal sphincter to relax. It is not spasm of the lower esophageal sphincter (choice D) , as some might imagine, or a primary lack of propulsive motility (choice E) .

Achalasia is an esophageal motor disorder that is characterized by the failure of the lower esophageal sphincter to relax and also by the loss of tertiary stripping waves in the lower esophagus. Because it is a motor disorder, the patient will have dysphagia for both solids and liquids from the onset of the condition. This disease can slowly progress. Endoscopy, barium swallow, and esophageal manometry can all be used in the evaluation of this condition. Definitive therapy is with pneumatic dilation or laparoscopic cardiomyotomy.