From the Guidelines
Investigations for achalasia cardia should include a comprehensive diagnostic workup, comprising clinical history, upper endoscopy, timed barium esophagram, and high-resolution manometry, with endoscopic functional luminal impedance planimetry (FLIP) as a useful adjunct test in equivocal cases. When evaluating patients for achalasia cardia, it is essential to consider the following key investigations:
- Clinical history and review of medications to establish the quality and severity of symptoms
- Upper endoscopy (esophagogastroduodenoscopy) to exclude pseudoachalasia and assess esophageal clearance, with findings such as frothy retained secretions and a puckered gastro-esophageal junction suggesting poor esophageal clearance 1
- Timed barium esophagram to show structural changes and confirm outflow obstruction, with the administration of a 13-mm barium tablet to elicit more subtle evidence for narrowing at the esophagogastric junction (EGJ) 1
- High-resolution manometry (HRM) as the gold standard for diagnosis, to define the subtype of achalasia according to the current Chicago classification system and guide phenotype-directed treatment 1
- Endoscopic functional luminal impedance planimetry (FLIP) as a useful adjunct test to confirm and complement HRM findings, particularly in cases with impaired EGJ opening 1 These investigations are crucial to comprehensively characterize anatomy and function, correlate with symptomatology, and guide treatment decisions, ultimately improving patient outcomes.
From the Research
Investigations for Achalasia Cardia
The investigations for achalasia cardia include:
- Upper gastrointestinal endoscopy to rule out mechanical obstruction due to stricture or malignancy 2, 3
- Barium swallow test to visualize the esophagus and rule out mechanical obstruction 2, 3, 4
- High-resolution esophageal manometry (HRM) for definitive diagnosis and classification of achalasia 2, 5, 6, 4
- Chest computed tomography (CT) to evaluate the esophagus and rule out underlying malignancy 3, 4
- Endoscopic ultrasound if an underlying malignancy is suspected 4
Diagnostic Evaluation
The diagnostic evaluation of achalasia cardia involves:
- Characterization of the type of achalasia using high-resolution manometry, which has important therapeutic implications 2, 5
- Evaluation of the esophagus using barium swallow test and chest CT to visualize the esophagus and rule out mechanical obstruction 3, 4
- Upper gastrointestinal endoscopy to rule out mechanical obstruction due to stricture or malignancy and to evaluate the esophagus 2, 3
Role of Investigations in Diagnosis
Investigations play a crucial role in the diagnosis of achalasia cardia, as they help to:
- Rule out mechanical obstruction due to stricture or malignancy 2, 3
- Characterize the type of achalasia, which has important therapeutic implications 2, 5
- Evaluate the esophagus and rule out underlying malignancy 3, 4
- Provide prognostic information, with type II achalasia being the most responsive to therapy 2, 4