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Weekly Chest CasesArchive of Old Cases

Case No : 961 Date 2016-03-28

  • Courtesy of Cherry Kim, Sang Young Oh, Sang Min Lee, Kyung-Hyun Do / Asan medical center
  • Age/Sex 30 / F
  • Chief ComplaintDyspepsia
  • Figure 1

Diagnosis With Brief Discussion

Diagnosis
Achalasia
Radiologic Findings
Posteroanterior chest radiograph shows an air-fluid level in the mediastinum at the level of distal trachea and bulging contour mass-like lesion in right paracardiac area. The right heart silhouette remains intact in face of the lesion shadow, suggesting that the lesion is located in the posterior mediastinum.
Esophagography shows markedly distended esophageal lumen with abrupt but smooth tapering at gastroesophageal junction level showing beak sign. Chest radiograph which obtained 5 hours after esophagography shows a changed air-fluid level (at the level of below carina) and residual contrast media in the distal esophagus which helps imagine the contour of the dilated esophagus along the mediastinum.
Computed tomography of the chest obtained with contrast enhancement also shows markedly dilated esophagus with air-fluid level.
Brief Review
Achalasia is defined by esophageal outflow obstruction from abnormal relaxation of the lower esophageal sphincter (LES) due to deranged inhibitory control. In genetically predisposed individuals, an autoimmune response to an unknown inciting agent, perhaps a viral infection, results in inflammation and sometimes loss of myenteric plexus ganglia and neurons. The net result is varying degrees of inhibitory dysfunction, at times associated with imbalanced and exaggerated excitatory function, with manometrically distinct achalasia phenotypes on high resolution manometry.
There are several types of achalasia. Type 1 achalasia, with esophageal outflow obstruction and absent esophageal body contractility, is an end-stage phenotype. Type 2 achalasia is characterized by panesophageal compartmentalization of pressure in the untreated patient, and partial recovery of peristalsis after treatment. Esophageal outflow obstruction with premature peristalsis (type 3 achalasia) or intact peristalsis may result from plexitis in the myenteric plexus but can also be encountered in other settings including chronic opioid medication usage and structural processes at the esophagogastric junction and distally. In most instances when idiopathic esophageal outflow obstruction is confirmed, some form of pharmacologic manipulation or disruption of the LES provides durable symptom relief.
References
1. Gyawali CP. Achalasia: new perspectives on an old disease. Neurogastroenterol Motil. 2016 Jan. 28 (1):4-11.
2. Pandolfino JE, Gawron AJ. Achalasia: a systematic review. JAMA. 2015 May 12. 313 (18):1841-52.
Keywords
Esophagus, Others,

No. of Applicants : 114

▶ Correct Answer : 64/114,  56.1%
  • - NIMS, HYDERABAD , India bhaskar kakarla
  • - SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OOKUBO
  • - Himeji Redcross Hospital , Japan Soichiro Okamoto
  • - Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
  • - Juntendo University Hospital , Japan Akifumi Hagiwara
  • - privato , Italy genchi enzo
  • - Seoul national university hospital , Korea (South) Kumju Chae
  • - Ewha Womans University Hospital , Korea (South) YOOKYUNG KIM
  • - Asan Medical Center , Korea (South) Ji Ye Lee
  • - King Abdulaziz University Hospital , Saudi Arabia Amr Ajlan
  • - SMG-SNU Boramae Medical Center , Korea (South) Hyoun Cho
  • - Korea University Guro Hospital , Korea (South) Hwanseok Yong
  • - Korea University Guro Hospital , Korea (South) Jeong Woo Kim
  • - Chonnam National University Hospital , Korea (South) So yeon Ki
  • - Seoul National University Hospital , Korea (South) Sunkyung Jeon
  • - Shiga University of Medical Science , Japan Akitoshi Inoue
  • - Khoo Teck Phuat Hospital Singapore , Singapore ashish chawla
  • - Policlinico Umberto I , Italy Paolo Baldassari
  • - Goa Medical College , India Paresh Desai
  • - SNUH , Korea (South) Juil Park
  • - University of Tsukuba, Dept of Radiologt , Japan Manabu Minami
  • - Northern Yokohama Showa university , Japan Kota Watanabe
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Daejin Medical Center Bundang Jesaeng General Hospital , Korea (South) Donghwan Kim
  • - The University of Tokyo Hospital , Japan Takeyuki Watadani
  • - Okayama University Hospital , Japan Toshiyuki Komaki
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - The first affiliated Hospital of Xiamen University , China Qing Qiang Guo
  • - Fortis hospital , Mohali , India Shaleen Rana
  • - Seoul national university , Korea (South) Boram Kim
  • - Santosh hospital,Bengaluru , India Pravin Mahadevappa
  • - chosun university hospital , Korea (South) Eunju Yoon
  • - DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
  • - DELTA CARE HOSPITAL, THANJAVUR, INDIA , India SIVARAJA SUBRAMANIAM
  • - Tokyo university, Japan , Korea (South) Hoon Noh
  • - Ulsan University Hospital , Korea (South) Soyeoun Lim
  • - Niigata University , Japan Atsushi Uehara
  • - The Jikei university , Japan Taku Gomi
  • - Maimonides Medical Center , United States naomi twersky
  • - National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida
  • - University of Toronto , Canada Micheal McInnis
  • - Ajou university hospital , Korea (South) Hye Lin Kim
  • - MT agarwal hospital,Mulund, Mumbai , India ASHISH SARODE
  • - Ajou University Hospital , Korea (South) Seulgi You
  • - , Korea (South)
  • - Seoul National University Bundang Hospital , Korea (South) Ji Eun Park
  • - , Korea (South) BAEK YOOLIM
  • - chungbuk national university hospital , Korea (South) soojung lee
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Korea university medical center, guro hospital , Korea (South) LEE CHONG
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Department of Radiology, Seoul National University Bundang Hospital , Korea (South) Sung Hyun Yoon
  • - Chonnam Nationl University Radiology , Korea (South) juwon kim
  • - Chonnam national university hospital , Korea (South) INSOO JANG
  • - Chonnam national university hospital , Korea (South) Jong-hyeon Kim
  • - NASA SCANS , India RAKESH BHATIA
  • - CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
  • - Kyung Hee University Hospital at Gangdong , Korea (South) Han Na Lee
  • - University of Tsukuba Hospital , Japan Shioto Oda
  • - Maternity & child hospital , Saudi Arabia Sania ALBlushi
  • - NEUROCITI DIAGNOSTICS , India Justin Moses
  • - University of Tsukuba Hospital , Japan Hiroaki Takahashi
  • - Private sector , Greece Vasilios Tzilas
  • - Himeji Red Cross Hospital , Japan Mayu Uka
▶ Correct Answer as Differential Diagnosis : 6/114,  5.3%
  • - McGill University Health Center , Canada Alexandre Semionov
  • - GHICL , France manuel toledano
  • - Avrasya Hospital , Turkey Murat Ulusoy
  • - Chungbuk national university , Korea (South) Yong Kim
  • - chungbuk university hospital , Korea (South) Hyeonmi Ryu
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
▶ Semi-Correct Answer : 5/114,  4.4%
  • - Kyungpook national university , Korea (South) Chungeun Lim
  • - MBAL BURGAS , Bulgaria VLADISLAV RUSINOV
  • - HIA legouest , France matthieu pernin
  • - the first affiliatited hospital of nanjing medical univercity , China Hai Xu
  • - bundang jesaeng , Korea (South) kyung su kwag
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