Chest 14

Salient findings:

1. Significantly distended oesophagus which is fluid and debris filled back to its origin.

2. No gross oesophageal wall thickening.

3. No significant abnormality identified at the gastro-oesophageal junction.

4. Diffuse bilateral central ground glass opacification within the lungs.

5. Patchy tree-in-bud changes.

6. No dense consolidation.

7. Chest X ray confirms the dilated oesophagus. There is also subtle increased central hazy nodular opacification which represents the inflammation of the alveoli seen in pneumonitis.

Principle Diagnosis:

Achalasia with complication of acute aspiration pneumonitis

Learning points:

Achalasia v Pseudoachalasia – Primary or secondary?

Achalasia is a functional abnormality where the Lower Oesophageal Sphincter fails to relax due to degeneration or loss of inhibitory neurons within the myenteric plexus.

Pseudoachalasia results in lower oesophageal obstruction as a result of a non-functional organic aetiology.

Potential causes of Pseudoachalasia:

1. Oesophageal malignancy

2. Gastric adenocarcinoma at the gastroesophageal junction

3. Scleroderma

4. Metastatic disease to the distal oesophagus, most likely culprits being lymphoma, breast or lung ca.

5. Amyloidosis infiltration of the brainstem

6. Sarcoidosis

7. Brainstem infarcts resulting in neuropathy and denervation

8. Peptic strictures and inflammation at the cardia/GOJ

9. Post- fundoplication

How is primary achalasia diagnosed?

1. Manometry which assesses the pressure across the lower oesophageal sphincter as well as the absence of normal peristalsis

2. Secondary confirmatory tests such as barium swallow and endoscopy are often adjuncts to the investigation.

Complications of achalasia:

1. Oesophageal carcinoma

2. Mid to upper oesophagus

3. More likely to be a squamous cell carcinoma

4. Result of food and debris stasis and resulting chronic inflammation resulting in statis oesophagitis.

5. Aspiration pneumonitis

6. Aspiration pneumonia with infection and consolidation

7. Candida oesophagitis

8. Oesophageal perforation

9. Gastroesophageal reflux disease

Usefulness of radiology?

1. Adjunctive tests such as barium swallow in the initial diagnosis

2. "Bird’s beak" oesophagus

3. Assessing for underlying secondary causes of Pseudoachalasia

4. Assessment of complications