SGD Case: GI 1

Patient is a 50-year-old male with a chief complaint of dysphagia.

He has difficulty swallowing both solid foods and liquids, and occasionally he regurgitates. The
problem is most noticeable when he is under stress and especially when he eats too fast. He
says that it feels like food is “stuck” in his esophagus and will not go down. He lost 10 pounds in
the past 2 months.

After doing a complete physical examination, the physician ordered several tests, including a
barium swallow and esophageal manometry. After the testing, he was diagnosed with
achalasia, a disease characterized by impaired peristalsis in the distal two-thirds of the
esophagus and failure of the lower esophageal sphincter (LES) to relax during swallowing. The
physician recommended a procedure that physically dilates the LES.
Guide Questions:

1. Describe and sequence the events during normal swallowing.

2. What is the role of esophageal peristalsis in normal swallowing?
3. In a normal swallow, what events occur in the LES, and what is the timing of these
events? What is the innervation of the LES, and what transmitters are involved in its
function?
4. How is achalasia responsible for patient’s difficulty swallowing and regurgitation? How
does it explain the feeling of food stuck in the esophagus?
5. On barium swallow testing, the radiologist noted dilation of the esophagus. How can
you explain this finding?
6. Results of patient’s esophageal manometry (pressure measurements) are shown in
figure above and compared to results in normal persons. What major differences are
seen in achalasia as compared to normal, and what is the explanation for these
differences?