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Achalasia and oesophageal motility disorders (including Zenker's)
In achalasia the lower oesophageal sphincter fails to relax and the oesophagus loses peristalsis; manometry makes the diagnosis, and a tumour at the gastro-oesophageal junction must be excluded before treatment.
Why it matters in the exam
The classic case is a young patient with difficulty swallowing both solids and liquids, regurgitation of undigested food and weight loss. Questions test the order of work-up: gastroscopy to exclude a tumour ("pseudo-achalasia"), a barium swallow showing a "bird's beak", and high-resolution manometry, which confirms the diagnosis and divides it into three Chicago subtypes. Difficulty with solids only that worsens steadily points instead to a stricture or a tumour.
The second part is the choice of treatment: pneumatic dilation, laparoscopic Heller myotomy with a partial fundoplication, or POEM — endoscopic division of the muscle, which suits type III especially well. Botulinum injection is kept for patients unfit for anything else. Candidates are also asked about distal oesophageal spasm (a "corkscrew" on barium), Zenker's diverticulum in an older patient with bad breath and regurgitation, and the raised risk of squamous cancer in long-standing achalasia.
Key points
- Achalasia = non-relaxing lower sphincter and absent peristalsis; dysphagia to solids and liquids.
- Gastroscopy first (pseudo-achalasia), and manometry makes the diagnosis.
- Treatment: pneumatic dilation, Heller with partial fundoplication, or POEM (type III).
- Botulinum only for those unfit for other treatment.
- Zenker's — older patient, bad breath; barium, not blind endoscopy.
Summary table
| Disorder | Clinical picture | Decisive test | Treatment |
|---|---|---|---|
| Achalasia | Dysphagia for both solids and liquids, regurgitation, weight loss | Manometry: non-relaxing sphincter and absent peristalsis; barium — "bird's beak" | Pneumatic dilation, Heller myotomy with partial fundoplication, or POEM |
| Pseudo-achalasia | Older patient, rapid weight loss, short history | Gastroscopy and CT: tumour at the gastro-oesophageal junction | Treat the tumour |
| Distal oesophageal spasm | Intermittent chest pain and dysphagia | Manometry: premature contractions; barium — "corkscrew" | Calcium-channel blockers, nitrates; POEM in severe cases |
| Zenker's diverticulum | Older patient, regurgitation of undigested food, bad breath, cough | Barium swallow (not blind endoscopy) | Cricopharyngeal myotomy, endoscopic or open |
| Peptic stricture | Long-standing heartburn, progressive dysphagia to solids only | Gastroscopy with biopsy | Dilation and PPI |
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Sources
- ACG Clinical Guideline: Diagnosis and Management of Achalasia, 2020 — Diagnosis, pneumatic dilation, myotomy and POEM
- Chicago Classification of oesophageal motility disorders, version 4.0 (2021) — Achalasia subtypes and other motility disorders
- Sabiston Textbook of Surgery, 21st edition (2022) — Esophagus
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.