Question

Which of the following investigations will help to differentiate esophageal achalasia from benign mechanical strictures of esophagogastric junction?

• A. \( \text{Chest X-ray} \)
• B. \( \text{Barium swallow} \)
• C. \( \text{Endoscopy} \)
• D. \( \text{Manometry} \)

Hint:

\textbf{Gastroenterology: Esophageal Disorders.} When evaluating esophageal symptoms like dysphagia, it's important to consider both structural (e.g., strictures, tumors) and functional (e.g., achalasia, motility disorders) causes. Often, a combination of investigations, including endoscopy and manometry, is needed for accurate diagnosis.

Answer 1

The Correct Option is C

Differentiating esophageal achalasia from benign mechanical strictures at the esophagogastric junction requires investigations that can assess both the structural and functional aspects of the esophagus. Let's evaluate the options: Chest X-ray: While a chest X-ray might show a dilated esophagus in advanced achalasia, it is not specific enough to differentiate it from a mechanical stricture. It provides limited information about the esophageal mucosa or the pressure dynamics at the lower esophageal sphincter (LES). Barium swallow: A barium swallow can reveal the characteristic "bird's beak" appearance of the distal esophagus in achalasia due to the failure of the LES to relax. It can also show the location and degree of narrowing in a stricture. However, it might not always clearly distinguish between the smooth tapering of achalasia and a more discrete stricture, especially if the stricture is benign and not severely obstructing. Endoscopy: Endoscopy involves the direct visualization of the esophageal mucosa using a flexible endoscope. This allows for the identification of structural abnormalities such as strictures, their location, and their appearance (e.g., smooth, irregular, ulcerated). Importantly, endoscopy can also rule out malignancy as a cause of the stricture and allows for biopsies to confirm a benign nature. While endoscopy can provide indirect signs of achalasia (e.g., dilated esophagus, retained food), it does not directly assess the LES pressure or relaxation. Manometry: Esophageal manometry is the gold standard for diagnosing achalasia. It measures the pressure and coordination of esophageal muscle contractions and the relaxation of the LES. In achalasia, manometry typically shows absent or incomplete LES relaxation with swallowing and a lack of coordinated peristalsis in the esophageal body. While manometry is excellent for diagnosing the functional abnormality of achalasia, it does not directly visualize the esophageal mucosa to assess for structural strictures. To differentiate between esophageal achalasia (a functional disorder) and a benign mechanical stricture (a structural abnormality), endoscopy is crucial for direct visualization and tissue sampling (biopsy) to characterize the stricture and rule out other causes like malignancy. While barium swallow can suggest both conditions, and manometry is key for diagnosing achalasia, endoscopy provides the most direct structural information needed for differentiation.