Achalasia

Achalasia:

Inability of the lower esophageal sphincter to relax during swallowing. 

Often the boards throws this symptom out as a distractor for a patient with GERD, which can be due to the lower esophageal sphincter relaxing at the wrong time (when not swallowing) this allow acid to reflux into the esophagus.

Caused by lack of Vasoactive Inhibitory Peptide (VIP), loss of myenteric (Auerbach's) plexus in the muscularis externa.

Abnormal contractions along the entire esophagus affecting lower, middle and upper esophagus. 

Key Symptom to differentiate from Odynophagia =

In Achalasia patients will have dysphagia to solids, liquids or both with or without pain Odynophagia = painful swallowing of food (usually). Odynophagia is the main symptom of esophagitis and esophogeal candidiasis

Swallowing reflex is initiated by the somatic nervous system (voluntary) and then becomes autonomic (involuntary).

There will be increased pressure lower esophageal sphincter (LES)

Poor peristalsis 

Barium swallow = initial test = "Bird's Beak" sign = distended esophagus with narrowing at the LES = hallmark for Achalasia

Best Dx test = manometry of esophagus will show aperistalsis, increases LES pressure, incomplete sphincter relaxation with swallowing.

Don't be fooled:

Dysphagia = difficulty with swallowing seen in achalasia 

Odynophagia = pain with swallowing = esophagitis and esophageal candidiasis.

Esophogeal Cancer = patients present with difficulty swallowing, 1st to solids then later to fluids.

Zenker Diverticulum = pouch in esophagus associated with halitosis and feeling of food being stuck in esophagus.

Esophogeal Web (Plummer Vinson syndrome) = associated with iron deficiency anemia, difficulty swallowing solids