Imaging

Achalasia

Preliminary Diagnosis: Achalasia

I. What imaging technique is first-line for this diagnosis?

Single-contrast barium esophagram

II. Describe the advantages and disadvantages of this technique for diagnosis of achalasia.

Advantages

  • Can accurately depict characteristic appearance of achalasia

  • Inexpensive

  • No signficant complications typify this outpatient procedure

  • Can suggest diagnosis of pseudoachalasia

Disadvantages

  • Exposure to ionizing radiation

  • Does not accurately differentiate between achalasia and pseudoachalasia. Typically followed up with endoscopic evaluation and manometry

  • A normal exam does not exclude early achalasia.

III. What are the contraindications for the first-line imaging technique?

  • Barium sulfate is contraindicated if suspected gastrointestinal perforation. The use of water-soluble oral contrast can be used if clinically indicated.

  • Double-contrast imaging is contraindicated.

IV. What alternative imaging techniques are available?

  • Helical CT of the chest with oral contrast

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of achalasia.

Helical CT of the chest with oral contrast

Advantages

  • useful in the workup of pseudoachalasia

Disadvantages

  • CT findings of achalasia are nonspecific. More useful in workup of suspected pseudoachalasia

  • Must be followed up with other tests such as barium esophagography, upper gastrointestinal endoscopy, or esophageal manometry

  • Uses higher radiation dose

  • Cost

VI. What are the contraindications for the alternative imaging techniques?

  • Helical CT of the chest with or without contrast

  • Relative contraindication in pregancy

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