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the usefulness of barium studies and various whether the patient’s age, the duration of dyspha- (90%). In two patients, the distal esophagus
clinical parameters for differentiating these gia, the length of the narrowed distal esophageal had a tortuous (i.e., sigmoid) configuration.
conditions. segment, or the diameter of the proximal esopha- The gastric cardia and fundus appeared nor-
gus was significantly associated with achalasia eti- mal in 10 patients (34%) but could not be ad-
ology (i.e., primary versus secondary achalasia).
equately evaluated because of delayed
Materials and Methods
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Fig. 1.—50-year-old man with primary Fig. 2.—23-year-old woman with primary achalasia. Spot ra- Fig. 3.—60-year-old man with secondary
achalasia. Spot radiograph from double- diograph from double-contrast barium study shows 3.5-cm- achalasia caused by lung carcinoma. Spot ra-
contrast barium study shows 1-cm-long long, gradually tapered segment of narrowing (straight diograph from single-contrast barium study
smooth, tapered narrowing (straight arrows ) in distal esophagus with esophageal diameter proxi- shows 5-cm-long symmetric, tapered narrow-
arrow ) of distal esophagus with esoph- mally of 7 cm and standing column of barium (curved arrow ). ing (arrows) of distal esophagus with esoph-
ageal diameter proximally of 6 cm. Note This was longest segment of narrowing shown on radiogra- ageal diameter proximally of 6 cm. Note fine
standing column of barium (curved arrow ) phy in a patient with primary achalasia. irregularity of contour of distal esophagus
on this upright view. Short length of nar- above narrowed segment caused by super-
rowed segment is characteristic of primary imposed infection with Candida esophagitis
achalasia. organisms proven on endoscopy.
Endoscopic, Manometric, CT, and Surgical Findings fundus; endoscopic biopsy specimens revealed patients with this condition. In the remaining
Primary achalasia.—Twenty-five of the 29 carcinoma of the cardia in two of these patients. 60%, the narrowed segment was smooth and
patients with primary achalasia had typical The third had carcinoma of the cardia at sur- symmetric with tapered proximal borders
findings of achalasia on manometry [1, 15]. In gery. In three patients with lung carcinoma, (Figs. 3 and 4). Therefore, secondary achalasia
all 29 patients, endoscopy revealed a closed chest CT scans revealed mediastinal adenopa- would not be suspected in most cases solely on
lower esophageal sphincter that opened in re- thy and mediastinal invasion by tumor. In the the basis of classic radiologic criteria. However,
sponse to the advancing endoscope, allowing it remaining patient with endometrial carcinoma, the narrowed distal esophageal segment was
to pass into the gastric fundus [15]. an abdominal CT scan revealed widespread in- longer than 3.5 cm in 80% of patients with sec-
Secondary achalasia.—Eight of the 10 pa- traperitoneal metastases, and a bone scan re- ondary achalasia, and an unusually long seg-
tients with secondary achalasia underwent en- vealed diffuse osseous metastases. Although ment of narrowing was the only suspicious
doscopy, which revealed a closed lower this patient did not have a chest CT scan, she finding in 40% (Figs. 3 and 4). In contrast, the
esophageal sphincter in all cases; the endoscope was presumed to have secondary achalasia be- narrowed segment was 3.5 cm or shorter in all
could not be advanced into the stomach in four cause of her widely disseminated endometrial patients with primary achalasia (Figs. 1 and 2).
of these patients, a finding that has been associ- carcinoma, advanced age (87 years), and short Therefore, the length of the narrowed distal
ated with secondary achalasia [6, 15–17]. Three duration of dysphagia (3 months). esophageal segment was a useful and statisti-
patients had esophageal carcinoma at endos- cally significant criterion for differentiating
copy, with infiltrative lesions in the distal esoph- secondary achalasia from primary achalasia on
Discussion
agus in two and in the upper esophagus in one; barium studies ( p < 0.0001).
endoscopic biopsy specimens revealed squa- In our study, barium studies revealed classic In our series, the degree of esophageal dila-
mous cell carcinoma in all three patients. Three findings of secondary achalasia with an eccen- tation above the narrowed segment was also a
other patients had carcinoma of the cardia on tric, nodular, or shouldered segment of distal statistically significant criterion for differentiat-
endoscopy, with polypoid masses in the gastric esophageal narrowing (Fig. 5A) in only 40% of ing secondary achalasia from primary achalasia
Fig. 4.—87-year-old woman with ( p < 0.0001). The diameter of the esophagus at
secondary achalasia caused by car- its widest point was 4 cm or less in 80% of pa-
cinoma of uterus. Spot radiograph
from double-contrast barium study tients with secondary achalasia, whereas the di-
shows 4-cm-long smooth, tapered ameter of the esophagus was greater than 4 cm
narrowing (arrows ) of distal esoph- in 90% of patients with primary achalasia. The
agus with esophageal diameter
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18]. In our series, however, the cardia and fun- lap in the clinical presentation has been re- the literature. Am J Gastroenterol 1979;71:24–29
dus could not be adequately evaluated radio- ported for all these parameters [17, 24]. In 6. Kahrilas PJ, Kishk SM, Helm JF, Dodds WJ, Harig
JM, Hogan WJ. Comparison of pseudoachalasia
graphically in 66% of patients with primary our series, the duration of dysphagia was a
and achalasia. Am J Med 1987;82:439–446
achalasia and in 50% with secondary achalasia statistically significant clinical criterion for 7. Feczko PJ, Halpert RD. Achalasia secondary to
because of delayed emptying of barium from differentiating secondary achalasia from pri- nongastrointestinal malignancies. Gastrointest Ra-
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the esophagus. Therefore, it is important to be mary achalasia ( p < 0.0001); all patients diol 1985;10:273–276
aware of the limitations of barium studies in with secondary achalasia had dysphagia for 8. Joffe N. Right-angled narrowing of the distal
evaluating the cardia and fundus in patients 4 months or less, whereas 97% of patients oesophagus secondary to carcinoma of the tail of
with suspected achalasia. with primary achalasia had dysphagia for 1 the pancreas. Clin Radiol 1979;30:33–37
9. Eaves R, Lambert J, Rees J, King RWF. Achalasia
In the past, some investigators have advo- year or more. The age of the patient was also
secondary to carcinoma of the prostate. Dig Dis Sci
cated amyl nitrite inhalation as a simple test a statistically significant but somewhat less 1983;28:278–284
for differentiating primary and secondary useful criterion for differentiating these con- 10. Ferreira-Santos R. Aperistalsis of the esophagus
achalasia on barium studies. It has been ditions ( p = 0.03); 80% of patients with sec- and colon etiologically related to Chagas’ disease.
shown that inhalation of amyl nitrite, a ondary achalasia and 38% with primary Am J Dig Dis 1961;6:700–726
smooth-muscle relaxant, has no effect on the achalasia were more than 60 years old. In 11. Ott DJ. Motility disorders. In: Gore RM, Levine
MS, Laufer I, eds. Textbook of gastrointestinal ra-
narrowed distal esophageal segment in sec- two previously published series, 28–30% of
diology. Philadelphia: Saunders, 1994:346–359
ondary achalasia but causes a measurable in- patients with primary achalasia were also 12. Seaman WB, Wells J, Flood CA. Diagnostic prob-
crease of 2 mm or more in the caliber of this found to be more than 60 years old [17, 24], lems of esophageal cancer: relationship to achala-
segment in primary achalasia [19]. Neverthe- limiting the usefulness of this criterion. sia and hiatus hernia. AJR 1963;90:778–791
less, this technique has not gained wide- In conclusion, only 40% of patients in our se- 13. Marshak RH, Eliasoph J. Cardiospasm or carci-
spread acceptance. ries had classic radiographic features of second- noma? The roentgen findings. Am J Dig Dis 1957;
2:11–25
Although our investigation focused on the ary achalasia such as eccentricity, nodularity, or
14. Tucker HJ, Snape WJ, Cohen S. Achalasia second-
usefulness of barium studies for differentiat- shouldering of the narrowed distal esophageal ary to carcinoma: manometric and clinical fea-
ing the two forms of achalasia, CT may also segment, or suspicious findings in the region of tures. Ann Intern Med 1978;89:315–318
be useful in these patients. CT typically re- the gastric cardia or fundus. Instead, the most 15. Reynolds JC, Parkman HP. Achalasia. Gastroen-
veals little or no esophageal wall thickening useful criteria for differentiating secondary terol Clin North Am 1989;18:223–255
and no evidence of a mass at the cardia in pa- from primary achalasia were the length of the 16. Rozman RW, Achkar E. Features distinguishing
tients with primary achalasia [20–22]. In narrowed segment and the degree of proximal secondary achalasia from primary achalasia. Am J
Gastroenterol 1990;85:1327–1330
some cases, however, CT may reveal a dilatation, and the most useful clinical criterion
17. Tracey JP, Traube M. Difficulties in the diagnosis
pseudomass at the cardia in patients without was the duration of dysphagia. When findings of pseudoachalasia. Am J Gastroenterol 1994;
tumor because of inadequate distention of of achalasia are present on barium studies, a 89:2014–2018
this region [23]. In contrast, CT may show narrowed distal esophageal segment longer than 18. Levine MS. Other malignant tumors. In: Gore RM,
asymmetric thickening of the distal esoph- 3.5 cm with little or no proximal dilatation in a Levine MS, Laufer I, eds. Textbook of gastrointesti-
ageal wall, a soft-tissue mass at the cardia, or patient with recent onset of dysphagia should be nal radiology. Philadelphia: Saunders, 1994:479–498
19. Dodds WJ, Stewart ET, Kishk SM, Kahrilas PJ,
mediastinal adenopathy in patients with sec- considered highly suggestive of secondary
Hogan WJ. Radiologic amyl nitrite test for distin-
ondary achalasia [21]. CT may also be help- achalasia, even in the absence of other suspi- guishing pseudoachalasia from idiopathic achala-
ful for identifying the site of the primary cious radiographic findings. sia. AJR 1986;146:21–23
tumor in patients with secondary achalasia 20. Rabushka LS, Fishman EK, Kuhlman JE. CT eval-
caused by remote tumors. uation of achalasia. J Comput Assist Tomogr 1991;
Various clinical parameters are also pur- References 15:434–439
ported to be useful for differentiating pri- 1. Katz PO, Castell DO. Review: esophageal motility 21. Carter M, Deckmann RC, Smith RC, Burrell MI,
disorders. Am J Med Sci 1985;290:61–69 Traube M. Differentiation of achalasia from
mary achalasia from secondary achalasia,
2. Cassella RR, Brown AL, Sayre GP, Ellis FH. pseudoachalasia by computed tomography. Am J
including the age of the patient, the duration Achalasia of the esophagus: pathologic and etio- Gastroenterol 1997;92:624–628
of dysphagia, and substantial weight loss. logic considerations. Ann Surg 1964;160:474–487 22. Tishler JM, Shin MS, Stanley RJ, Koehler RE. CT
Primary achalasia is more likely to occur in 3. Csendes A, Smok G, Braghetto I, Ramirez C, Ve- of the thorax in patients with achalasia. Dig Dis Sci
younger patients (<50 years old) with long- lasco N, Henriquez A. Gastroesophageal sphincter 1983;28:692–697
standing dysphagia (>1 year) and little or no pressure and histological changes in distal esopha- 23. Marks WM, Callen PW, Moss AA. Gastroesoph-
gus in patients with achalasia of the esophagus. ageal region: source of confusion on CT. AJR 1981;
weight loss (<7 kg) [15, 18], whereas sec-
Dig Dis Sci 1985;30:941–945 136:359–362
ondary achalasia is more likely to occur in 24. Sandler RS, Bozymski EM, Orlando RC. Failure
4. Lawson TL, Dodds WJ. Infiltrating carcinoma simu-
older patients (>60 years old) with recent on- lating achalasia. Gastrointest Radiol 1976;1:245–248 of clinical criteria to distinguish between primary
set of dysphagia (<6 months) and substantial 5. McCallum RW. Esophageal achalasia secondary to achalasia and achalasia secondary to tumor. Dig
weight loss (>7 kg) [14]. Nevertheless, over- gastric carcinoma: report of a case and review of Dis Sci 1982;27:209–213