Beyond visualizing the bird beak: esophagram, timed barium esophagram and manometry in achalasia and its 3 subtypes

Abstract

Achalasia is a rare esophageal motility disorder characterized by lack of primary peristalsis and a poorly relaxing lower esophageal sphincter. This disease process can be examined several ways and these evaluations can offer complementary information. There are three manometric subtypes of achalasia, with differing appearances on esophagram. Differentiating them is clinically important, because treatment for the subtypes varies. Timed barium esophagram (TBE) is a simple test to quantitatively evaluate esophageal emptying. TBE can be used to diagnose achalasia and assess treatment response. Considerable variation in the TBE protocol exist in the literature. We propose a standardized approach for TBE to allow for comparison across institutions.

Keywords: Achalasia; Esophagram; Manometry; Timed barium esophagram.

Fig. 1

From Hertz, A.F., Achalasia of the Cardia (so-called Cardio-spasm). Proc R Soc Med, 1915. 8(Clin Sect): p. 22–25. Used with permission

Fig. 2

Legend—X-axis is time in seconds, Y-axis is distance in centimeters. In high-resolution manometry, colors are used to represent pressure in a color contour plot. The cooler colors (blue and green) represent lower pressures and warmer colors (red and orange) representing higher pressures. High resolution manometry allows achalasia to be differentiated into three subtypes based on manometric patterns. X-axis is time in seconds, Y-axis is distance in centimeters. In high-resolution manometry, colors are used to represent pressure in a color contour plot. The cooler colors (blue and green) represent lower pressures and warmer colors (red and orange) representing higher pressures. Image 1 Type I achalasia (classic) has absent smooth muscle contractility in the esophageal body with an elevated median IRP > 15 mmHg. Image 2 Type II achalasia has ≥ 20% of swallows of panesophageal pressurization and an elevated median IRP > 15 mmHg. Image 3 Type III achalasia (spastic/vigorous) has shortened distal latency (< 4.5 s), DCI > 450 mmHg cm s and an elevated median IRP > 15 mmHg

Fig. 3

Fluoroscopic image of type III achalasia shows multiple segmental contractions (black arrow) with smooth tapering at the LES (white arrow)

Fig. 4

Fluoroscopic image showing type II achalasia. The esophagus is nondilated, and there are contractions that indent but do not obliterate the esophageal lumen (arrow)

Fig. 5

Fluoroscopic image showing type I achalasia. Esophagus is dilated, with fluid level on this upright image (white arrow). There is smooth tapering at the LES (black arrow)

Fig. 6

Fluoroscopic image showing sigmoid esophagus. The esophagus is markedly dilated and tortuous, with angulation of the esophagus (arrows)

Fig. 7

Fluoroscopic image of distal esophageal carcinoma. There is longer segment narrowing of the distal esophagus than is typical of achalasia, and the narrowed segment is neither smooth nor centric (arrow)

Fig. 8

Following ingestion of barium, an LPO radiograph at 5 min demonstrates a columnation of contrast. Vertical arrow shows column height. Horizontal arrow shows column width

Fig. 9

Proposed timed barium esophagram protocol

Fig. 10

Abnormal TBE showing columns at 1, 2, and 5 min (black arrows). The barium tablet did not pass after 5 min (white arrow)

Fig. 11

An example of column height and width measurements. LPO radiograph 5 min after ingestion of barium in type 1 achalasia in a patient with a sigmoid esophagus