A 43 year Old Woman With Progressive Difficulty With Swallowing

A 43 year old woman presents to a gastroenterologist on referral for progressive difficulty with swallowing. She says over the past several years she has difficulty swallowing both solid foods and liquids. More recently she has had episodes of coughing during eating and she feels she is aspirating small amounts of food during these episodes. She occasionally gets heart burn and she feels she is losing weight because of difficulty eating food.
A barium swallow was done as a part of workup and is shown below:

What is the Diagnosis?
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Achlasia

Case discussion:
Achlasia is a neuromuscular disorder of the esophagus characterized by impaired peristalsis and decreased relaxation of lower esophageal sphincter resulting in dysphagia.

• Most commonly is is an idiopathic condition affecting patients 20 to 60 years of age.
• Patients present with difficulty in swallowing due to impaired transport of food through the esophagus.
• Patients have difficulty in swallowing both solids as well as liquids.
• Barium swallow demonstrates a dilated esophagus with a 'bird's beak' taper at the site of lower esophageal sphincter. 
• Esophageal manometry demonstrates increased LES pressure, incomplete relaxation of LES and impaired peristalsis.
• Treatment may be done with nitrates and calcium channel blockers that help relax LES but have limited benefits.
• Endoscopic injection of botulinium toxin provides relief for most patients.
• 'Myomectomy may be performed for refractory cases