A 48-year-old male presents with a 6-month history of progressive dysphagia. He first noted difficulty swallowing solids and liquids on occasion but now has difficulty with every meal. He has nocturnal regurgitation of undigested food. There is no history of heartburn. He has experienced a 10-pound weight loss in the past 2 months. He is a nonsmoker and nondrinker. On physical exam, the patient is afebrile, the lungs are clear to auscultation, and there are no heart murmurs. The abdomen is soft, nontender, and nondistended. Pulses are equal bilaterally. Several weeks before presenting to you, he was seen in the emergency department where the following chest x-ray was taken.

Signs and symptoms of dysphagia and weight loss raise concerns regarding esophageal cancer. The nature of this patient’s dysphagia, which involves solids and liquids equally, is more suggestive of a benign process. A peptic stricture might be considered, but the lack of a history compatible with gastroesophageal reflux disease makes this diagnosis unlikely. Endos copy is necessary to evaluate for malignancy as a cause for the dysphagia the patient is experiencing. If no mass is seen, and if the lower esophageal sphincter is easily traversed with the endoscope, pseudoachalasia can be ruled out as well. The clinical signs and symptoms are then most consistent with a motility disorder.

When motility disorder is suspected, a contrast esophagram is usually helpful in confirming the diagnosis. Manometry is always necessary to diagnose diffuse esophageal spasm and high-amplitude peristaltic contractions of the esophagus (nutcracker esophagus). Manometry is sometimes necessary to diagnose achalasia conclusively when the clinical presentation is questionable. In patients with a typical clinical picture, a normal endoscopic examination, and a typical barium swallow, the clinical diagnosis of achalasia usually is certain, and recommendations regarding therapy can be made without the need for manometry.