PMC5808260_01
Initial barium esophagram: Bird beaks appearance and irregularity of the EGJ, dilated distal esophagus.
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A barium esophagogram revealed a delayed passage of contrast media to the stomach and a dilated distal esophagus with an irregularity in the esophago-gastric junction (EGJ) (Figure 1).
Initial high resolution esophageal manometry image documenting segmental aperistalsis (A) in the distal esophagus from about 6cm above the LES, normal propagation of the peristaltic wave (B) with a normal distal latency (DL) of 5.85s (normative >4.5s) and a poorly relaxing lower esophageal sphincter (LES) defined by an integrated relaxation pressure (IRP4s) of 20.2 mmHg (normative <17 mmHg in achalasia type III) and a residual pressure of 21 mmHg (normative <8mmHg) with a slightly elevated resting pressure of 46mmHg (normative 10-45 mmHg).
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The HRM contraction patterns are depicted in Figure 2.
High resolution esophageal manometry following botulinum toxin injection to the LES recording documenting segmental aperistalsis in the distal esophagus, normal propagation of the peristaltic wave with a normal distal latency (DL) (normative >4.5s) and a near normal relaxing lower esophageal sphincter (LES) defined by a residual pressure of 9.1 mmHg (normative <8 mmHg) with a normal resting pressure of 24.8 mmHg (normative 10-45 mmHg).
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The high-resolution esophageal manometry measurements 6 weeks after BoTox injection found a near normal relaxation of the LES but still simultaneous contractions from the mid to the distal esophagus with a normal DL (Figure 3).
High resolution esophageal manometry 4 years after initial examination. Aperistalsis of the whole esophageal body (A). Distal latency 4.6s (DL) (normative >4.5s). Poorly relaxing LES defined by an IRP4s of 21.4 mmHg (normative <17 mmHg in achalasia type III) and residual pressure of 8 mmHg (normative <8 mmHg). LES at the upper border of normal with 43 mmHg (normative 10-45 mmHg).
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The criteria proposed by the Chicago classification for achalasia type III were met (Figure 4).
Barium esophagram 4 years after initial presentation.
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The barium esophagram showed a similar picture as the previous examination, with narrowing of the EGJ and a dilated esophagus (Figure 5).