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 that provides valuable information on esophageal morphology and function. 1

Role of Esophagogram in Achalasia

Esophagograms serve multiple important purposes in achalasia management:

• Diagnostic value: Videofluoroscopy has a sensitivity of 80-89% and specificity of 79-91% for diagnosing esophageal motility disorders, including achalasia, compared to manometry 2
• Characteristic findings: Can reveal the classic "bird's beak" appearance and esophageal dilation typical of achalasia 1
• Treatment planning: Helps assess the degree of esophageal dilation and guides treatment selection 1
• Treatment response monitoring: Particularly useful for evaluating improvement after interventions 3

Types of Esophagograms for Achalasia

Biphasic Esophagogram

• Provides superior mucosal detail
• Combines double-contrast and single-contrast techniques
• Requires patient cooperation
• Preferred when possible for comprehensive evaluation 2, 1

Single-Contrast Esophagogram

• May be necessary for debilitated patients who cannot tolerate double-contrast studies
• Still provides valuable information about esophageal emptying 2

Timed Barium Esophagogram (TBE)

• Specialized technique that objectively assesses esophageal emptying
• Valuable for predicting treatment outcomes
• Patients with less than 50% improvement in barium column height at 1 minute post-treatment have a 40% risk of treatment failure 4

Patient Preparation Considerations

• Extended fasting: Patients with achalasia may require prolonged fasting (beyond standard 4-6 hours) 1
• Esophageal lavage: May be necessary to clear retained food and secretions before the procedure 1
• Informed consent: Should be obtained in line with local hospital policies 1

Clinical Pearls and Pitfalls

• Diagnostic limitations: While valuable, esophagogram alone is insufficient for definitive diagnosis of achalasia; high-resolution manometry remains the gold standard for confirmation 1
• Complementary testing: Esophagogram should be used alongside manometry and endoscopy for comprehensive evaluation 1, 5
• Misdiagnosis risk: Achalasia is commonly misdiagnosed initially as gastroesophageal reflux disease; proper imaging helps avoid this pitfall 6
• Occasional superiority to manometry: In some cases, barium studies may reveal dysmotility not seen at manometry (e.g., some patients with beak-like distal esophageal narrowing of achalasia are found to have complete relaxation of the lower esophageal sphincter on manometry) 2

Post-Treatment Evaluation

• Esophagography is ideally suited to evaluate potential post-treatment complications 3
• Can detect complications such as intramural dissection, leaks, scarring, fibrosis, strictures, and problems related to gastroesophageal reflux 3
• The height of the barium column at 1 minute post-treatment correlates significantly with symptom scores for dysphagia, chest pain, and overall dysphagia severity 4

Esophagogram remains a cornerstone in the management of achalasia patients, providing critical information for diagnosis, treatment planning, and monitoring that directly impacts patient morbidity, mortality, and quality of life.