Achalasia x ray

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Achalasia Microchapters


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Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2] Ahmed Younes M.B.B.CH [3]


Achalasia is caused by insufficient lower esophageal sphincter (LES) relaxation causing obstruction at gastro-esophageal junction. It leads to absent peristalsis and stasis of food in esophagus. To perform an X ray with barium swallow, the patient swallows a barium solution, which fails to pass smoothly through the lower esophageal sphincter. An air-fluid margin is seen over the barium column due to the lack of peristalsis. Narrowing is observed at the level of the gastroesophageal junction ("bird's beak" or "rat tail" appearance of the lower esophagus). Esophageal dilation is present in varying degrees as the esophagus is gradually stretched by retained food. A five-minute timed barium swallow is useful to measure the effectiveness of treatment.


Esophagram is less sensitive than manometry in diagnosing early stages of achalasia.

Radiologic Findings Suggestive of Achalasia[1]

  • "Bird's beak image" or "rat tail" appearance due to narrowing of esophagus at gastroesophageal junction.
  • Dilated esophageal body
  • Air fluid level due to absent peristalsis
  • Absence of an intragastric air bubble
  • In advanced achalasia - sigmoid appearance

Role of Contrast Studies in Diagnosis

  • To support manometry in diagnosing achalasia[2]
  • To assess esophageal emptying and morphology in cases of equivocal findings on motility testing
  • To look for achalasia changes in later stages (such as tortuosity, megaesophagus and angulation)
  • To assess esophageal emptying after treatment. Timed barium esophagram (TBE) is used to identify patients who are more likely to relapse despite initial improvement in their symptoms after treatment
  • To rule out structural abnormality
  • To look for presence of epiphrenic diverticula
  • To look for any esophageal thickening
Case courtesy of A.Prof Frank Gaillard,, rID: 7948
Case courtesy of Dr Mario Umana,, rID: 38071
Case courtesy of A.Prof Frank Gaillard,, rID: 8054
Case courtesy of Dr Mario Umana,, rID: 38071

Timed Barium Esophagram

Height of barium coloumn is measured in esophagus at 1 and 5 min after patient ingests a large bolus of barium in upright position. Data has suggested that TBE results can predict therapeutic success and requirement for further interventions. Vaezi et al found strong association between TBE results and symptomatic relief after pneumatic dilation.[3]

  • Fluoroscopy can be used to demonstrate the lack of peristaltic waves in the smooth-muscle portion of the esophagus. It may also reveal ‘vigorous’ achalasia, which is characterized by random spastic contractions in the esophagus.



  1. Boeckxstaens GE, Zaninotto G, Richter JE (2013). "Achalasia". Lancet. doi:10.1016/S0140-6736(13)60651-0. PMID 23871090.
  2. Vaezi MF, Pandolfino JE, Vela MF (2013). "ACG clinical guideline: diagnosis and management of achalasia". Am J Gastroenterol. 108 (8): 1238–49, quiz 1250. doi:10.1038/ajg.2013.196. PMID 23877351.
  3. Vaezi MF, Baker ME, Richter JE (1999). "Assessment of esophageal emptying post-pneumatic dilation: use of the timed barium esophagram". Am J Gastroenterol. 94 (7): 1802–7. doi:10.1111/j.1572-0241.1999.01209.x. PMID 10406238.

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