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Diagnosis?
Achalasia
This is a classic presentation. Here's the breakdown:
Key findings pointing to Achalasia:
- Dysphagia to BOTH solids AND liquids - this is the hallmark. Mechanical obstructions (cancer, stricture) cause dysphagia to solids first, then liquids. Simultaneous solid + liquid dysphagia = motility disorder.
- Regurgitation of undigested food (especially evening meals) - food sits in the esophagus, not the stomach, so it returns undigested.
- Retrosternal discomfort after eating.
- Barium esophagram: distal tapering - the classic "bird's beak" sign at the lower esophageal sphincter (LES).
- Dilated esophagus with retained debris - food accumulating due to failed LES relaxation.
- Absent gastric air bubble on CXR - the LES won't open, so no air passes into the stomach.
- Unintentional 6 kg weight loss - chronic inability to eat.
- From rural Bolivia - this is a critical clue for Chagas disease (Trypanosoma cruzi infection), which destroys the myenteric (Auerbach's) plexus and causes secondary achalasia.
Mechanism:
In primary achalasia, degeneration of inhibitory neurons in the myenteric plexus leads to:
- Failure of LES relaxation
- Loss of peristalsis in the esophageal body
In Chagas-related achalasia (this patient's likely etiology given rural Bolivia origin), T. cruzi causes the same neuronal destruction, producing an identical clinical picture.
Confirmatory test: Esophageal manometry (high-resolution) - shows elevated LES resting pressure, incomplete LES relaxation, and aperistalsis.
Treatment options: Pneumatic dilation, Heller myotomy (laparoscopic), or peroral endoscopic myotomy (POEM).
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