A 57-year-old woman complains of a sensation of esophageal compression, palpitations, difficult breathing when eating solid food, occasional vomiting with a full mouth, "wet pillow" sign at night for the last 6 months. Objectively: body tempearture -39°C, height - 168 cm, weight - 72 kg, Ps-76/min, BP- 120/80 mm Hg. X-ray study revealed considerable dilation of esophagus and its constriction in the cardial part. What pathology is the most likely to have caused dysphagia in this patient?

Answer options

1. Achalasia cardiae
2. Hiatal hernia
3. Reflux esophagitis
4. Primary esophageal spasm
5. Esophageal carcinoma

Explanation

The physiological abnormalities are a non-relaxing LOS and absent peristalsis in the body of the esophagus. In its earliest stages, the esophagus is of normal caliber and still exhibits contractile (although non-peristaltic) activity. In some patients, these uncoordinated contractions result in pain as much as a sense of food sticking. With time, the esophagus dilates, and contractions disappear so that the esophagus empties by the hydrostatic pressure of its contents. This is always incomplete, leaving residual food and fluid. The gas bubble in the stomach is frequently absent, as no bolus with its accompanying normal gas passes through the sphincter. The ‘megaesophagus’ becomes tortuous with persistent retention esophagitis due to fermentation of food residues and this may account for the increased incidence of carcinoma of the esophagus. The disease is most common in middle life but can occur at any age. It typically presents with dysphagia, although pain (often mistaken for reflux) is common in the initial stages. Patients often present late and, having had mild symptoms, remain untreated for many years. Regurgitation is frequent, and there may be overspill into the trachea, especially at night. Diagnosis Achalasia may be suspected at endoscopy by finding a tight cardia and food residue in the esophagus. Barium radiology may show hold-up in the distal esophagus, abnormal contractions in the esophageal body, and a tapering stricture in the distal esophagus often described as a ‘bird’s beak’. The gastric gas bubble is usually absent. These typical features of well-developed achalasia are often absent, and endoscopy and radiology can be normal. A firm diagnosis is established by esophageal manometry. Classically, the LOS does not relax completely on swallowing, there is no peristalsis and there is a raised resting pressure in the esophagus. The LOS pressure may be elevated but is often normal. Bailey & Love’s short practice of surgery. – 25th edition. – P. 1035.