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Diagnosis of Primary Versus Secondary Achalasia

Reassessment of Clinical and Radiographic Criteria

¹ All authors: Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104.

View larger version (61K): [in a new window]   Fig. 1. —50-year-old man with primary achalasia. Spot radiograph from double-contrast barium study shows 1-cm-long smooth, tapered narrowing (straight arrow) of distal esophagus with esophageal diameter proximally of 6 cm. Note standing column of barium (curved arrow) on this upright view. Short length of narrowed segment is characteristic of primary achalasia.

View larger version (86K): [in a new window]   Fig. 2. —23-year-old woman with primary achalasia. Spot radiograph from double-contrast barium study shows 3.5-cm-long, gradually tapered segment of narrowing (straight arrows) in distal esophagus with esophageal diameter proximally of 7 cm and standing column of barium (curved arrow). This was longest segment of narrowing shown on radiography in a patient with primary achalasia.

View larger version (53K): [in a new window]   Fig. 3. —60-year-old man with secondary achalasia caused by lung carcinoma. Spot radiograph from single-contrast barium study shows 5-cm-long symmetric, tapered narrowing (arrows) of distal esophagus with esophageal diameter proximally of 6 cm. Note fine irregularity of contour of distal esophagus above narrowed segment caused by superimposed infection with Candida esophagitis organisms proven on endoscopy.

View larger version (103K): [in a new window]   Fig. 4. —87-year-old woman with secondary achalasia caused by carcinoma of uterus. Spot radiograph from double-contrast barium study shows 4-cm-long smooth, tapered narrowing (arrows) of distal esophagus with esophageal diameter proximally of 3.5 cm. As in Figure 3, a narrowed segment longer than 3.5 cm should be considered highly suggestive of secondary achalasia, even lacking other suspicious radiographic findings.

View larger version (105K): [in a new window]   Fig. 5A. —63-year-old man with secondary achalasia caused by carcinoma of esophagus. Spot radiograph from double-contrast barium study shows 4-cm-long eccentric, tapered narrowing (arrows) of distal esophagus with esophageal diameter proximally of 4 cm.

View larger version (99K): [in a new window]   Fig. 5B. —63-year-old man with secondary achalasia caused by carcinoma of esophagus. Additional spot radiograph shows annular carcinoma with relatively abrupt, shelflike margins (arrows) in upper thoracic esophagus.

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