Preliminary Diagnosis: Achalasia

I. What imaging technique is first-line for this diagnosis?

Single-contrast barium esophagram

II. Describe the advantages and disadvantages of this technique for diagnosis of achalasia.


  • Can accurately depict characteristic appearance of achalasia

  • Inexpensive

  • No signficant complications typify this outpatient procedure

  • Can suggest diagnosis of pseudoachalasia


  • Exposure to ionizing radiation

  • Does not accurately differentiate between achalasia and pseudoachalasia. Typically followed up with endoscopic evaluation and manometry

  • A normal exam does not exclude early achalasia.

III. What are the contraindications for the first-line imaging technique?

  • Barium sulfate is contraindicated if suspected gastrointestinal perforation. The use of water-soluble oral contrast can be used if clinically indicated.

  • Double-contrast imaging is contraindicated.

IV. What alternative imaging techniques are available?

  • Helical CT of the chest with oral contrast

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of achalasia.

Helical CT of the chest with oral contrast


  • useful in the workup of pseudoachalasia


  • CT findings of achalasia are nonspecific. More useful in workup of suspected pseudoachalasia

  • Must be followed up with other tests such as barium esophagography, upper gastrointestinal endoscopy, or esophageal manometry

  • Uses higher radiation dose

  • Cost

VI. What are the contraindications for the alternative imaging techniques?

  • Helical CT of the chest with or without contrast

  • Relative contraindication in pregancy

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