Achalasia Differential Diagnoses

Updated: Dec 28, 2017
  • Author: Marco Ettore Allaix, MD, PhD; Chief Editor: Praveen K Roy, MD, AGAF  more...
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DDx

Diagnostic Considerations

Cancer of the gastroesophageal junction

The invasion of the esophageal neural plexus by the tumor can cause nonrelaxation of the LES, thus mimicking achalasia. This condition is known as malignant pseudoachalasia. Since contrast radiography and endoscopy frequently fail to differentiate these 2 entities, patients with a presumed diagnosis of achalasia but who have a shorter duration of symptoms, greater weight loss, and a more advanced age and who are referred for minimally invasive surgery should undergo additional imaging studies, including endoscopic ultrasound and computed tomography with fine cuts of the gastroesophageal junction, to rule out cancer.

Esophageal perforation

Pneumatic dilatation for achalasia carries a significant and recognized risk of esophageal perforation. Therefore, an informed consent emphasizing this risk of perforation must be obtained from patients prior to the dilatation.

After the dilatation, administer a small amount of water-soluble contrast material to evaluate for perforation. This should be performed in all patients undergoing the procedure. If no perforation is noted, the patient's diet can be advanced slowly after a period of observation.

Patients with a small perforation without any evidence of infection or communication with the pleural or peritoneal cavities may receive conservative therapy with broad-spectrum antibiotics and close observation in the hospital.

A surgical consultation must be obtained as soon as a perforation is identified. Any clinical deterioration or communication with the mediastinum or pleural or peritoneal cavities necessitates surgical intervention.