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Achalasia — ABIM Board MCQ

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ModerateGastroenterology/HepatologyAchalasiaABIM Board

A 48-year-old man has an 8-month history of progressive dysphagia to both solids and liquids, regurgitation of undigested food, and nocturnal coughing. Upper endoscopy reveals a mildly dilated esophagus containing retained saliva. The mucosa is normal, no stricture or mass is present, and the endoscope passes through the gastroesophageal junction with mild resistance. A barium esophagram demonstrates delayed esophageal emptying with smooth, symmetric tapering of the distal esophagus at the gastroesophageal junction. Which of the following is the most likely diagnosis?

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Correct answer: B — Achalasia

Achalasia is the best diagnosis. Dysphagia to both solids and liquids suggests an esophageal motility disorder rather than a fixed mechanical lesion. Regurgitation of undigested food, nocturnal cough, retained saliva in a dilated esophagus, and smooth tapering with delayed emptying at the gastroesophageal junction are characteristic. Endoscopy excludes an obstructing lesion causing pseudoachalasia; high-resolution manometry would confirm impaired junctional relaxation and absent peristalsis. Peptic stricture usually causes predominantly solid-food dysphagia with a visible narrowing. Eosinophilic esophagitis causes solid-food dysphagia or impaction, often with rings or furrows. Zenker diverticulum produces oropharyngeal symptoms and a cervical pouch. Diffuse esophageal spasm more often causes intermittent dysphagia and chest pain with premature contractions, rather than persistent gastroesophageal-junction outflow obstruction.

Reference: Vaezi MF, Pandolfino JE, Yadlapati RH, et al. ACG Clinical Guidelines: Diagnosis and Management of Achalasia. Diagnostic Testing section. American Journal of Gastroenterology. 2020. https://pubmed.ncbi.nlm.nih.gov/32773454/