Achalasia, Esophageal Spasm and EoE oh my!

Today in VA morning report we had a lively discussion about esophageal problems with the lead discussant being our local esophagus expert Dr. Dunbar! Some quick PEARLS below!

Achalasia –

  • Typically presents with dysphagia to both solids and liquids
  • Represents failure of relaxation of the LES (in most cases)
  • Remember to perform an EGD on anyone with suspected achalasia in order to rule our “pseudoachalasia” which may be secondary to malignancy.
  • Once EGD is performed, you can confirm achalasia with esophageal manometry.
  • Treatment typically depends on whether the patient is low or high risk for surgery
    • For low risk – Heller myotomy and pneumatic dilatation are the treatments of choice.  Some studies show they are eually as effective
    • For high risk – medical management with botulism injection into the LES can be very helpful

Diffuse Esophageal Spasm –

  • Usually presents with chest pain
  • Has a Corkscrew appearance on barium swallow caused by abnormal muscle contractions
  • Treatment is medical and the drug of choice is a calcium channel blocker like diltiazem.
  • Less effective treatments include nitrates and botulinum toxin

Eosinophilic Esophagitis – EoE

  • Typically presents with dysphagia, food impaction, chest pain, and GERD
  • EGD shows concentric rings and trachealization of the esophagus
  • Biopsy will show many eosinophils (but this can also occur in GERD)
  • Always treat with omeprazole first, because 30-40% of cases will respond to this!
  • If not steroid responsive, fluticasone or budesonide inhalers can be used. These are sprayed into the mouth without inhalation, and then swallowed
  • Pneumatic dilatation can be used for strictures as last resort, but there is increased risk of perforation!!

Thank you Dr. Dunbar for your excellent input on the disorders!



Imm, Nick. Achalasia. Digital image. N.p., 11 Aug. 2011. Web. 24 July 2017. <>.

Nevit, Dilman. Corkscrew Esophagus. Digital image. Wikipedia. N.p., 13 Dec. 1993. Web. 24 July 2017. <>.