General Surgery · Year 3 · from General Surgery
Case 2: Achalasia
Patient Demographics
- Age: 38 years
- Sex: Female
- Occupation: Veterinarian
Chief Complaint
"I have difficulty swallowing both solids and liquids, and food gets stuck in my chest."
History of Present Illness
The patient reports a 2-year history of progressive dysphagia affecting both solids and liquids equally. She describes a sensation of food "sticking" in her lower chest. She has learned to eat slowly and drink water to help food go down. She frequently regurgitates undigested food, especially when lying down at night. She has lost 5 kg over the past year. She denies heartburn (in fact, notes decreased reflux symptoms over time). She occasionally has chest pain, particularly with eating.
Past Medical History
- Mild GERD symptoms years ago (now resolved)
- Otherwise healthy
Medications
- None
Physical Examination
- Vitals: Normal
- General: Thin female, appears well
- Neck/Chest: No abnormalities
- Abdomen: Soft, non-tender
Diagnostic Workup
Barium Swallow:
- Dilated esophagus with "bird's beak" narrowing at the GE junction
- Delayed esophageal emptying
- No hiatal hernia
Upper Endoscopy:
- Dilated esophagus with retained food debris
- Tight lower esophageal sphincter requiring gentle pressure to traverse
- Normal-appearing gastric mucosa
- Biopsies: Negative for malignancy or eosinophilic esophagitis
High-Resolution Esophageal Manometry:
- Absent peristalsis in esophageal body (100% failed swallows)
- Elevated integrated relaxation pressure (IRP) of 22 mmHg (normal <15)
- Elevated LES resting pressure
- Findings consistent with Type II achalasia (panesophageal pressurization)
Timed Barium Esophagram:
- 1-minute column height: 8 cm
- 5-minute column height: 6 cm (impaired emptying)
Diagnosis
Type II Achalasia (Chicago Classification v4.0)
Treatment Options Discussed
- Pneumatic dilation: Effective but may require repeat procedures; perforation risk 1-3%
- Heller myotomy + partial fundoplication: Durable results, 90% success rate
- POEM (peroral endoscopic myotomy): Minimally invasive, excellent short-term results; higher GERD rate
- Botulinum toxin injection: Temporary, reserved for poor surgical candidates
Given her age, Type II disease (best response to intervention), and desire for durable results, patient chose laparoscopic Heller myotomy with Dor fundoplication.
Operative Procedure
- Laparoscopic Heller myotomy
- Myotomy extended 6 cm on esophagus and 2.5 cm onto stomach
- Anterior (Dor) fundoplication to prevent reflux
- Intraoperative endoscopy confirmed complete myotomy and no mucosal injury
Postoperative Course
- Swallow study POD 1: No leak, improved passage
- Clear liquid diet started POD 1
- Diet advanced slowly over 2 weeks
- Discharged POD 2
Follow-up
- 2 weeks: Tolerating soft diet, no dysphagia
- 3 months: Eating normal diet, gained 3 kg
- Timed barium esophagram: Marked improvement in esophageal emptying
- 1 year: Minimal reflux symptoms controlled with occasional antacids, excellent quality of life
Teaching Points
- Achalasia: Absent peristalsis + impaired LES relaxation
- Dysphagia to both solids AND liquids suggests motility disorder
- Barium swallow shows "bird's beak" appearance
- High-resolution manometry is gold standard for diagnosis
- Treatment aims to reduce LES pressure (myotomy or dilation)
- Partial fundoplication prevents post-myotomy reflux
- Long-term surveillance important (slightly increased esophageal cancer risk)
Clinical Image
Image Description: Barium swallow demonstrating the classic "bird's beak" appearance of achalasia. The dilated esophageal body tapers smoothly to a narrow point at the gastroesophageal junction due to the non-relaxing lower esophageal sphincter.
Attribution: Image from Wikimedia Commons, Category:Esophageal cancer. Source: https://commons.wikimedia.org/wiki/Category:Esophageal_cancer