Achalasia: Heller Myotomy and Toupet Fundoplication

Brant K. Oelschlager, MD; Eelco B. Wassenaar, MD, PhD; Laura Filippa, MD


February 16, 2010

Clinical Presentation

Mrs. S is 53 years old and complains of dysphagia that started approximately 11 months ago and has become worse. She has problems swallowing solids as well as liquids. Occasionally she has some regurgitation of food. She has lost 7 kg of weight. She has no other symptoms and claims that 1 year ago she did not have any swallowing problems. Her past medical and surgical histories reveal hypertension and a tonsillectomy. Her medication includes aspirin and metoprolol. She has no allergies and does not smoke or drink. The differential diagnosis of this patient is:

  • Esophageal neoplasm: this diagnosis needs to be ruled out in the patient with dysphagia and weight loss;

  • Achalasia: the most common esophageal motility disorder leading to (worsening) dysphagia, regurgitation, weight loss;

  • Large hiatal hernia: can lead to dysphagia but also symptoms of gastro-esophageal reflux, pain, or anemia;

  • Esophageal diverticulum: when symptomatic it can lead to regurgitation;

  • Other esophageal motility disorder, such as hypercontractile esophagus or diffuse esophageal spasm (DES).

Results of Esophagogastroduodenoscopy

An esophagogastroduodenoscopy (EGD) was performed that did not show signs of hiatal hernia or esophagitis, and no diverticulum was seen. The EGD did show narrowing of the distal esophagus with retained food, although when the scope was passed into the stomach and retroflexed, no sign of gastroesophageal junction (GEJ) tumor was found. Biopsies were negative for malignancy or dysplasia. The endoscopist noticed that no normal peristaltic waves were seen in the esophagus.

Question 1. What is the most likely diagnosis of this otherwise healthy middle-aged woman?

A. Esophageal neoplasm
B. Achalasia
C. Large hiatal hernia
D. Esophageal diverticulum
E. Other esophageal motility disorder

View the correct answer.