Can an esophagogram be performed in a patient with achalasia?

Esophagogram in Patients with Achalasia

Yes, an esophagogram can and should be performed in patients with achalasia as it is an essential diagnostic and monitoring tool for this condition. 1, 2

Diagnostic Role of Esophagogram in Achalasia

Initial Diagnosis

• Barium swallow/esophagogram is recommended to assess esophageal dilation, evaluate for the classic "bird's beak" appearance, and identify potential structural abnormalities in patients with suspected achalasia 2
• The study helps differentiate achalasia from other causes of dysphagia and can suggest the diagnosis before confirmation with manometry

Preferred Technique

• A biphasic esophagogram provides superior mucosal detail but requires patient cooperation 1
• For debilitated or less mobile patients, a single-contrast esophagram may be necessary 1
• Timed barium esophagogram (TBE) is particularly useful as it:
  • Directly measures esophageal emptying 3
  • Provides objective assessment of esophageal function 4
  • Is simple to perform and interpret 3

Pre-Procedure Considerations

Patient Preparation

• Patients with achalasia are particularly prone to esophageal stasis and may require:
  • More prolonged fasting (beyond the standard 4-6 hours) 1
  • Possible esophageal lavage to clear retained food and secretions 1

Safety Precautions

• Written informed consent should be obtained in line with local hospital policies 1
• Patients with achalasia may find procedures more uncomfortable and may require appropriate sedation 1
• Consider the addition of intravenous opiates as this is common practice for patients with achalasia 1

Role in Treatment Monitoring

Post-Treatment Assessment

• Esophagography is ideally suited to evaluate potential post-treatment complications 5
• TBE parameters correlate with symptom scores and can predict treatment outcomes 4
• Lack of improvement in barium column height post-treatment is associated with a 40% risk of treatment failure 4

Objective Measurement

• TBE provides objective confirmation of successful myotomy or dilation 3
• Symptoms alone are unreliable in assessing esophageal emptying, making objective imaging crucial 3

Complementary Diagnostic Tests

Relationship to Other Tests

• High-resolution manometry (HRM) remains the gold standard for confirming diagnosis and determining achalasia subtype 1, 2
• Endoscopy with biopsy is recommended to rule out malignancy, assess for esophageal dilation, and exclude other conditions 2
• Esophagogram provides complementary information to these tests

Special Considerations

Post-Procedure Monitoring

• Consider proton pump inhibitor (PPI) therapy after dilatation as the procedure has a 10-40% rate of symptomatic gastroesophageal reflux disease 1
• Monitor for at least 2 hours after any intervention 1

Potential Pitfalls

• Secondary achalasia should be considered during evaluation, including infectious and inflammatory causes 2
• Esophagogram alone cannot definitively diagnose achalasia - manometry is still required for confirmation 1
• Patients with achalasia are at increased risk of esophageal cancer and require appropriate surveillance 2

In conclusion, esophagogram is a valuable tool in the diagnostic workup and treatment monitoring of patients with achalasia, providing important anatomical and functional information that complements other diagnostic modalities.