A 37-year-old man comes to the physician because of a 6-month history of chest pain that occurs when he swallows food; he has had a 9-kg (20-lb) weight loss during this period. He has not had heartburn or increased sensitivity in his hands to cold temperatures. He is 178 cm (5 ft 10in) tall and now weighs 59 kg (130 lb); BMI is 19 kg/m2. Physical examination shows no abnormalities. A barium swallow shows esophageal dilation. Manometry shows a high resting pressure at the lower esophageal sphincter; there is little or no decrease in pressure associated with swallowing. Which of the following is the most likely diagnosis?
A. Achalasia
B. Esophagitis
C. Gastric ulcer
D. Gastroesophageal reflux disease (GERD)
E. Hiatal hernia
F. Systemic sclerosis (scleroderma)

Correct answer: A. Achalasia

This is a case of achalasia cardia characterised by failure of relaxation of lower esophageal sphincter. Difficulty in swallowing food, barium  swallow showing esophageal dilation, manometry showing high resting pressure of lower esophageal sphincter all point towards this diagnosis. Absence of heartburn helps rule out GERD. Absence of increased sensitivity in his hand to cold ( cold can precipitate spasm of digital vessels – Raynaud’s phenomenon) helps rule out systemic sclerosis.


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