This woman presents with a history suggestive of achalasia. This is indicated by the dysphagia of both solids and liquids occurring simultaneously, regurgitation, weight loss, and her past history of Chagas disease. Achalasia is an esophageal
motility disorder characterized by the absence of esophageal peristalsis and impaired relaxation of the lower esophageal sphincter in response to swallowing. The vast majority is of unknown etiology while a small percentage can be from Chagas disease, gastric carcinoma, and lymphoma. The most accurate diagnostic test to confirm achalasia is esophageal manometry (choice D), which shows increased lower esophageal resting pressure.
Esophagogastroduodenoscopy (choice A) is done when cancer red-flag symptoms such as anemia, heme-positive stools, weight loss, symptoms longer than 6 months in a patient >60 years old are present.
Chest plain radiography (choice B) may show an air-fluid level in the dilated esophagus, but it is not accurate enough to confirm the diagnosis.
Barium esophagography (barium swallow) (choice C) is a very accurate test and shows dilation of the esophagus, which narrows into the classic “bird’s beak” at the distal end; however, this is not the most accurate test available. Choose barium swallow if esophageal manometry is not in the answer choices.
Response to proton pump inhibitors (choice E) is a common way to confirm gastroesophageal reflux disease (GERD).
Dysphagia of both solids and liquids simultaneously accompanied by regurgitation and weight loss in a patient with a history of Chagas disease suggests achalasia. Esophageal manometry is the most accurate diagnostic test while barium esophagography is the second best test to accurately diagnose this condition.