PMC4699733_01
Patient's initial barium swallow which showed a mildly dilated esophagus with tertiary contractions, delayed emptying of the esophagus, and a narrowed gastroesophageal junction.
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The barium swallow showed a mildly dilated esophagus with tertiary contractions, delayed emptying of the esophagus, and a narrowed gastroesophageal junction (Fig. 1).
A representative swallow from the patient's initial high resolution esophageal manometry. The median integrated residual pressure was noted to be normal at 7 mmHg, the mean lower esophageal sphincter resting pressure was normal at 20 mmHg, and the distal contractile integral was elevated to 16,534 mmHg   sec   cm. The esophageal manometry was consistent with jackhammer esophagus.
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Given her progressive dysphagia symptoms and weight loss, a high resolution esophageal manometry (HREM) was performed (Fig. 2).
Patient's timed barium esophagram. There is a diffuse esophageal dilatation with retained esophageal secretions and barium with only 0-20% change in volume after 5 minutes. There are tertiary peristaltic waves within the distal esophagus, limited emptying of the contrast into the stomach and an air-fluid level.
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At this point, a timed barium esophagram was performed (Fig. 3).
A representative swallow from the patient's repeat high resolution esophageal manometry about a year later. The median integrated residual pressure was noted to be elevated at 143 mmHg and the mean lower esophageal sphincter resting pressure was also elevated at 122 mmHg. There is a 100% prolonged panesophageal pressurization. The esophageal manometry was consistent with type II achalasia.
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A repeat HREM was performed (Fig. 4) revealing a median integrated residual pressure of 71.5 mmHg, mean resting pressure of 97 mmHg, and mean residual pressure of 90 mmHg.