Oesophagus Flashcards
- Which is the most commonly affected site in systemic sclerosis after the oesophagus?
a. Small bowel
b. Colon
c. Stomach
d. Anorectal
e. Oropharynx
d. Anorectal
Esophagus is most frequently affected (75-90%) followed by ano-rectum (50-70%), small bowel (40%) and colon (10-50%). The stomach is the least affected in the GIT.
Which of the following are CT criteria for T3 rather than T2 oesophageal cancers?
A. Transmural enhancement
B. Focal wall thickening measuring 14mm
C. A few <1⁄3 small linear strands of soft tissue extending in to fat planes
D. Depth of 11mm
E. Slight stenosis
D. Depth of 11mm
T3 disease usually involves a large tumour more than 10mm in depth where > 1⁄3 tumour extension or a blurred fat plane around the lesion is associated with moderate/severe stenosis.
Focal wall thickening of 5-15mm is still T2 disease.
Which of the following represent a case of oesophageal pouch in the lower 1⁄3 of the oesophagus?
A. Intraluminal diverticulosis
B. Defect through Killian-Jamieson space
C. Mucosal tear/Mallory-Weiss
D. Zenker’s diverticulosis
E. Traction following treatment for TB
C. Mucosal tear/Mallory-Weiss
Mucosal tears from Mallory-Weiss syndrome or post-endoscopy are typically in lower 1⁄3 of the oesophagus.
- A 46-year-old woman with a multisystem disorder presents with dysphagia and heartburn. Barium swallow reveals a dilated oesophagus with aperistalsis of the lower two-thirds of the oesophagus, a patulous lower oesophageal sphincter and gastro-oesophageal reflux. Which other organ system is most likely to be affected?
A. respiratory
B. cardiovascular
C. skin
D. central nervous
E. renal
C. skin
The patient is suffering from systemic sclerosis, a multisystem connective tissue disorder of unknown etiology, classified by extent of skin involvement and overlap with other autoimmune disorders.
The skin is the most commonly involved organ, demonstrating thickening, atrophic changes and fibrosis.
The gastrointestinal system is the next most commonly affected, with around 50% of patients having symptomatic disease.
The oesophagus is most frequently involved, with fibrosis of the circular layer of smooth muscle resulting in a dilated oesophagus with absent or reduced peristalsis in the lower two-thirds.
The lower oesophageal sphincter is wide, in contrast to the tapered narrowing seen in achalasia.
Patients suffer from reflux that predisposes to Barrett’s oesophagus and distal strictures.
The cardiovascular, respiratory, central nervous and renal systems may all be affected in systemic sclerosis, though less commonly than the skin and gastrointestinal systems.
A 65-year-old man undergoes endoscopy for dysphagia, during which an ulcerated mass is seen in the distal oesophagus. Biopsy confirms oesophageal adenocarcinoma. What is the most accurate imaging modality for local staging of oesophageal cancer?
A. endoscopic ultrasound
B. CT
C. 18FDG PET/CT
D. MRI
E. barium swallow
A. endoscopic ultrasound
CT is the most commonly used imaging investigation for staging of oesophageal cancer. However, the overall accuracy of T staging is poor, particularly with T1 and T2 tumours, and CT also tends to overestimate tumour length.
Endoscopic ultrasound scan is the most accurate imaging method for local staging, but is limited in its assessment of nodal and metastatic disease.
18FDG PET/CT is useful in evaluation of nodal and metastatic disease, particularly in patients being considered for surgical resection, but has limited resolution for T staging and often fails to demonstrate T1 lesions.
MR is useful I characterization of indeterminate liver lesions seen on CT.
Barium swallow is not used in the staging of oesophageal cancer.
- A 23-year-old man with dysphagia undergoes a double-contrast barium swallow, which demonstrates a smooth, well-defined, 12 cm submucosal lesion in the distal oesophagus causing deformity of the lumen. CT demonstrates coarse calcification within the mass. What is the most likely diagnosis?
A. oesophageal lipoma
B. oesophageal duplication cyst
C. oesophageal carcinoma
D. oesophageal varices
E. oesophageal leiomyoma
E. oesophageal leiomyoma
Leiomyomas are benign tumours of smooth muscle, and represent the most common benign neoplasm of the oesophagus. They are often asymptomatic but may present with dysphagia and rarely hematemesis.
They appear on barium swallow as large, well-defined, intramural masses causing luminal deformity.
A characteristic finding is of coarse calcifications – leiomyoma is the only calcifying oesophageal tumour.
Oesophageal lipomas and duplication cysts also appear as well-defined submucosal lesions (of fat and of water density respectively on CT), but are less common, and internal calcification is not a feature.
Oesophageal carcinoma usually appears as an irregular ulcerated stricture.
Oesophageal varices are seen as serpiginous filling defects.
- A 70-year-old man with a history of several months of dysphagia undergoes double-contrast barium swallow. This demonstrates a moderately dilated oesophagus with reduced peristalsis and smooth tapering of the distal oesophagus. What is the most likely diagnosis?
A. primary achalasia
B. gastric carcinoma
C. scleroderma
D. oesophageal carcinoma
E. presbyoesophagus
B. gastric carcinoma
Primary achalasia is an abnormality of the myenteric plexus resulting in reduced or absent peristalsis and failure of relaxation of the lower oesophageal sphincter. The oesophagus is typically markedly dilated with absent primary peristalsis and a smooth tapered narrowing at the contracted lower oesophageal sphincter. It usually presents in young adults with long-standing dysphagia.
In contrast, secondary achalasia due to malignancy usually presents in older patients with a short duration of dysphagia. Decreased peristalsis and distal oesophageal tapering in these patients result from tumour infiltration of the myenteric plexus of the distal oesophagus by gastric carcinoma, lymphoma or metastatic disease.
Distal oesophageal carcinoma tends to give rise to irregular, asymmetrical narrowing.
Scleroderma typically appears as a dilated esophagus with a patulous lower oesophageal sphincter.
Presbyoesophagus is a disorder of oesophageal motility, characterized by oesophageal dilatation and repetitive, non-peristaltic, tertiary contractions in the distal oesophagus.
- A 56-year-old man presents acutely with chest pain after a night out. On examination he is febrile, tachycardic and hypotensive. Chest radiograph demonstrates extensive pneumomediastinum, with left pleural effusion and left lower lobe atelectasis. What is the most likely diagnosis?
A. acute pulmonary embolism
B. spontaneous oesophageal rupture
C. aortic dissection
D. lobar pneumonia
E. acute pancreatitis
B. spontaneous oesophageal rupture
Iatrogenic injury is the most common cause of oesophageal rupture, but, in 15% of cases, rupture is spontaneous and occurs during vomiting (Boerhaave’s syndrome). Patients present with pain and dysphagia, and rapidly develop sepsis. Characteristic chest radiograph findings are of extensive pneumomediastinum and subcutaneous emphysema, pleural effusion or hydropneumothorax, and left lower lobe atelectasis. Widening of the mediastinum may accompany the development of mediastinitis. Pleural effusion and atelectasis may be seen in acute pulmonary embolism, acute pancreatitis and aortic dissection, but pneumomediastinum is not a recognized feature of these conditions. Other common causes of pneumomediastinum include asthma, chest trauma and perforation of a hollow viscus with extension of gas via the retroperitoneum.
- A 26-year-old man known to have AIDS presents with a 2-week history of difficult and painful swallowing. He undergoes double-contrast barium examination of the oesophagus, which demonstrates multiple, small, superficial, round ulcers in the mid-oesophagus. The intervening mucosa is normal and no plaques are seen. What is the most likely diagnosis?
A. HIV esophagitis
B. cytomegalovirus esophagitis
C. reflux esophagitis
D. candida esophagitis
E. herpes simplex esophagitis
E. herpes simplex esophagitis
Candida esophagitis is the commonest cause of infectious esophagitis and is particularly seen in immunosuppressed individuals. It is frequently associated with oral thrush. It tends to affect the upper half of the oesophagus, and typical appearances are of linear, longitudinally oriented filling defects representing heaped-up areas of mucosal plaques consisting of necrotic debris and fungal colonies.
In contrast, a normal intervening mucosa in esophagitis is suggestive of a viral aetiology.
Findings in cytomegalovirus and HIV esophagitis are similar, with typical appearances of one or more large flat ulcers seen in the distal oesophagus. Distinction between the two is made by brushings or biopsy at endoscopy.
In herpes simplex infection, the typical features of multiple, small, superficial ulcers are similar at all sites of potential involvement, including the oesophagus, oral cavity, rectum and anus.
- A 45-year-old man undergoes barium swallow for dysphagia, which demonstrates multiple flask-shaped outpouchings of barium arranged in longitudinal rows paralleling the long axis of the oesophagus. Which of the following is a commonly associated condition?
A. scleroderma
B. rheumatoid arthritis
C. chronic obstructive airway disease
D. AIDS
E. diabetes
E. diabetes
Oesophageal intramural pseudo diverticulosis is a condition causing dilatation of the ducts of the submucosal glands of the oesophagus. These appear on barium meal as multiple, tiny, flask-shaped collections of barium arranged in longitudinal rows. They may appear to ‘float’ outside the oesophagus, as the connection to the lumen may not be appreciated. Associated strictures in the distal oesophagus are common. The condition is commonly associated with diabetes and chronic alcoholism, but may also occur with severe esophagitis of any cause. Candida may be cultured in around half the cases, but this may be a secondary infection due to stasis of secretions within the glands.
- What is the most common cause of varices affecting the upper third of the oesophagus?
A. portal hypertension due to cirrhosis
B. splenic vein thrombosis
C. inferior vena caval obstruction
D. superior vena caval obstruction
E. hepatic vein obstruction
D. superior vena caval obstruction
Oesophageal varices are dilated submucosal veins, which may be classified by their direction of flow as uphill or downhill varices.
Uphill varices occur in the lower esophagus and represent collateral blood flow conveying portal venous blood to treasons vein. They usually result from portal hypertension due to liver cirrhosis, but may also occur with splenic vein thrombosis, and obstruction of the hepatic veins or IVC.
Downhill varices result from obstruction of the SVC.
If it is obstructed superior to the entry of the azygos vein, varices will be confined to the upper third of the oesophagus.
If the SVC is obstructed below the entry of the azygos vein, the varices convey all of the systemic venous blood from the upper half of the body into the portal vein and IVC, and they will run the entire length of the oesophagus.
SVC obstruction is most commonly due to lung cancer or lymphoma.
- A 76-year-old woman presents with dysphagia and regurgitation of undigested food. She undergoes barium swallow, which demonstrates a barium-filled pouch extending from the posterior oesophageal wall at the level of C5–6 that is causing oesophageal compression. What is the most likely diagnosis?
A. intramural pseudodiverticulum
B. Epiphrenic diverticulum
C. lateral pharyngeal diverticulum
D. interbronchial diverticulum
E. Zenker’s diverticulum
E. Zenker’s diverticulum
A Zenker’s diverticulum is a herniation of the mucosa and submucosa through the midline of the posterior oesophageal wall at cleavage plane between the oblique and transverse fibres of cricopharyngeus (Killian’s dehiscence) at the level of C5–6.
The diverticulum is narrow necked and extends caudally, resulting in trapping of undigested food and compression of the adjacent oesophagus.
Epiphrenic diverticula are rare, usually occurring on the right lateral wall of the distal oesophagus in association with hiatus hernia. Lateral pharyngeal diverticula are herniations of pharyngeal mucosa through the lateral pharyngeal wall, which occur most commonly in wind instrument players, reflecting increased intrapharyngeal pressure. An interbronchial diverticulum is a traction diverticulum that occurs in the interbronchial segment of the oesophagus in response to adjacent fibrous adhesions following lymph-node infection (usually tuberculous). Intramural pseudodiverticula represent dilated excretory ducts of mucosal glands, which appear as multiple flask-shaped outpouchings and are commonly seen in association with candidiasis.
- A 68-year-old man undergoes barium swallow for dysphagia. During the examination the patient has an episode of coughing, and barium is noted to enter the larynx and proximal trachea. What is the appropriate management?
A. no action needed
B. physiotherapy
C. prophylactic antibiotics
D. chest radiograph in 48 hours
E. admission to hospital for observation
B. physiotherapy
Barium aspiration is a recognized complication of barium swallow, and may occur particularly in patients with swallowing disorders or recent oesophageal surgery. It is usually clinically insignificant, but complications have been reported, especially with aspiration of larger amounts of barium, and include pneumonitis and granuloma formation. Physiotherapy is the only treatment recommended. Of the water-soluble contrast agents, Gastrograffin (ionic and hyperosmolar) may cause pulmonary oedema if aspirated. Gastromiro (non-ionic and iso-osmolar) is safe to use if aspiration is a significant possibility
- Which structure marks the transition from squamous oesophageal to columnar gastric epithelium?
A. A-ring
B. B-ring
C. Z-line
D. oesophageal vestibule
E. gastro-oesophageal junction
C. Z-line
The transition from squamous oesophageal epithelium to columnar gastric epithelium is marked by the Z-line, an irregular zigzag line. It is not a reliable indicator of the gastrooesophageal junction, however, and may lie some distance above it if there is columnar transformation of the distal oesophagus, as seen in Barrett’s oesophagus. The gastrooesophageal junction may be identified by a thin, shelf-like ring known as the B-ring. It is visible on barium swallow only when the gastro-oesophageal junction lies above the diaphragmatic hiatus. Approximately 2–4  cm above this is a thicker ring produced by active muscle contraction known as the A-ring. The oesophageal vestibule is the saccular termination of the lower oesophagus, which lies between the A-ring and the B-ring, and corresponds with the lower oesophageal sphincter.
- At endoscopic ultrasound scan for staging of an oesophageal carcinoma, the tumour is seen extending into the hypoechoic fourth layer of the oesophagus but not beyond this. What is the T staging of the tumour?
A. Tis
B. T1
C. T2
D. T3
E. T4
C. T2
Endoscopic ultrasound is the most accurate method for local staging of oesophageal cancer. At endoscopic ultrasound, the oesophageal wall appears as five distinct alternating hyperechoic and hypoechoic bands that correspond to the histological layers of the oesophagus. The innermost hyperechoic layer represents the interface between the lumen and the mucosa. The hypoechoic second layer is a hypoechoic band that represents the muscularis mucosa. The third layer is a hyperechoic band that represents the submucosa. The fourth layer is a hypoechoic band that represents the muscularispropria. The fifth outermost layer is a hyperechoic band that represents the oesophageal adventitia. The fifth layer in the stomach, duodenum and rectum represents the serosa. For oesophageal cancer, T1 tumours invade the lamina propria or submucosa. T2tumours invade the muscularis propria, T3 tumours invade the adventitia and T4tumours invade adjacent tissue. Tis represents carcinoma in situ.
- A 47-year-old woman with dysphagia undergoes barium swallow, which demonstrates a persistent smooth posterior bulge at the pharyngo-oesophageal junction at the level of C5–6 with mild proximal pharyngeal dilatation. What is the most likely diagnosis?
A. normal findings
B. impaired cricopharyngeus relaxation
C. pharyngeal web
D. anterior cervical osteophytes
E. thyroid enlargement
B. impaired cricopharyngeus relaxation
Impaired cricopharyngeus relaxation (or cricopharyngeal achalasia) is hypertrophy of the cricopharyngeus muscle with failure of relaxation. It is seen in up to 10% of asymptomatic adults as a normal variant, as a compensatory mechanism in gastro oesophageal reflux, and in association with a range of neuromuscular disorders. It appears on barium swallow as a smooth, shelf-like posterior projection at the level ofC5–6 that persists during a swallow. In severe cases, it may result in functional obstruction or overflow aspiration. Symptomatic patients may be treated by cricopharyngeal myotomy. Pharyngeal webs are thin, anterior, shelf-like protrusions into the cervical oesophagus. They are frequent incidental findings but occasionally cause dysphagia. There is an association with Plummer–Vinson syndrome. Anterior osteophytes may cause an indentation of the posterior oesophagus, but these are usually asymptomatic. Thyroid enlargement may cause a smooth impression on the lateral wall of the oesophagus.
10 A young man presents to severe central chest pain following episode of vomiting. On questioning he reports that he has been drinking alcohol the night before. The CT shows an eccentric hyperattenuating mass within the wall of the oesophagus. What is the most likely diagnosis?
(a) Mallory-Weiss tear
(b) Intramural oesophageal dissection
(c) Boerhaave syndrome
(d) Transmural perforation
(e) Intramural hematoma
(e) Intramural hematoma
The CT features indicate an intramural haematoma. Such patients often have a history of instrumentation, vomiting or food impaction and present with sudden onset pain, dysphagia or odynophagia. Haematemesis tends to occur later in the clinical course. Mallory-Weise tear is a longitudinal mucosal laceration at the gastro-osophageal junction. Dissection gives a double-barreled -appearance of the lumen due to mucosal flap. Options (c) and (d) are full-thickness injuries and demonstrates mediastinal air or fluid on CT.
A 58-year-old lady is referred for staging of a carcinoma in the middle third of the oesophagus. Which of the following statements is true?
(a) Lymphatic drainage is likely to be via the upper abdominal lymph nodes
(b) A PET study can reliably exclude the presence of involved loco-regional nodes
(c) EUS is superior to PET-CT in the evaluation of loco-regional lymph nodes
(d) Following treatment, EUS most commonly under-stages residual disease.
(e) The adrenal glands are the commonest site Of metastatic disease
(c) EUS is superior to PET-CT in the evaluation of loco-regional lymph nodes
The upper and middle thirds of the oesophagus usually drain superiorly. Local staging is best performed with endoscopic US. PET-CT is the most accurate modality for distant lymph nodes or metastases but the intense uptake of the primary tumour may obscure local nodes. Following treatment, it is difficult to distinguish fibrosis from active tumour at EUS; PET is more accurate in this circumstance. The most common sites of metastases are, in order, liver, lungs bones and adrenal glands.
13 The junction of the squamous and columnar epithelium, the barium swallow, is given what term?
(a) A-ring
(b) B-ring
(c) Schatzki ring
(d) Barrett’s line
(e) Z-line
(e) Z-line
The A-ring is transient and muscular. The B- or Schatzki ring is a fixed mucosal/ muscular ring which may cause dysphagia or obstruction. Barrett’s stricture a complication of GE reflux disease and is premalignant.
7.A 42-year-old undergoes a barium swallow. This shows hold up of contrast medium in the lower oesophagus resolves completely when the patient is given a cup of hot water. What is the most likely diagnosis?
(a) Oesophageal varices
(b) Diffuse oesophageal spasm
(c) Presbyoesophagus
(d) Primary achalasia
(e) Intramural diverticulosis
(d) Primary achalasia
Patients often report that hot drinks provide relief in achalasia. On imaging, sphincter relaxes and oesophagus is seen clear.
17.A 46-year-old presents dysphagia and weight loss. He is noted to have hyperkeratosis of the palms and soles. Barium small shows a malignant stricture of the mid oesophagus. What is the most likely underlying diagnosis?
(a) Dermatomyositis
(b) Epidermolysis bullosa
(c) Pemphigus vulgaris
(d) Scleroderma
(e) Tylosis
(e) Tylosis
Tylosis is an autosomal dominant inherited disorder characterized by thickening (hyperkeratosis) of the palms and soles, oral leukoplakia, and SCC of the oesophagus (in 95 % by 70 yrs). Epidermolysis bullosa has a high association with SCC of the skin, there are rare case reports of associated oesophageal cancer. Pemphigus has a rare paraneoplastic form, typically associated with lymphoma. Dermatomyositis has a high association with various internal malignancies, in such cases it is thought to be a ‘paraneoplastic’ phenomenon, indicating the presence of cancer. Scleroderma results in oesophageal dysmotility, predisposing to reflux and increasing the risk of oesophageal cancer.
21.A patient a primary oesophageal tumour undergoes a PET.CT study using 18FDG before and after receiving 1 course of chemotherapy. In order to achieve a partial response, by how much does the standardized uptake value (SUV) need to fall between these 2 studies?
(a) 10 %
(b) 15 %
(c) 20 %
(d) 25 %
(e) 50%
(b) 15 %
The EORTC define a partial response as a 15% reduction at 1 cycle or 25% reduction at 2 or more cycles. Progressive disease is a 15% increase after 1 cycle or 25% after 2 or more cycles.
22.A 47-year-old woman undergoes a barium swallow. It is reported to show a diverticulum in the mid-oesophagus. What is the most likely etiology?
(a) Structural defect
(b) Pulsion
(c) Traction
(d) Reflux
(e) Achalasia
(c) Traction
In the upper oesophagus, a pharyngeal pouch may be seen as a structural defect. In the mid-oesophagus, traction from adjacent mediastinal or pulmonary fibrosis is most common, whereas pulsion causes lower-third diverticula.
A 47-year-old attends for a barium swallow. This shows a lacelike pattern in the oesophagus above a lax lower oesophageal sphincter. What is the most likely diagnosis?
(a) Barrett’s oesophagus
(b) Oesophageal varices
(c) Oesophageal carcinoma
(d) Oesophageal candidiasis
(e) Normal oesophageal mucosa
(a) Barrett’s oesophagus
Barrett’s oesophagus is dysplasia of the lower oesophageal mucosa as a consequence of chronic gastro-oesophageal reflux disease. It is a premalignant condition and patients are usually enrolled in a surveillance program.
- With regard to squamous cell carcinoma of the oesophagus, which of the following statements is not true?
(a) It is associated with alcohol ingestion
(b) It most commonly occurs in the middle third of the oesophagus
(c) It is common in Afro-Carribean population
(d) It is associated with smoking
(e) It is more common in women
(e) It is more common in women
It is most commonly seen (50% cases) in the middle third, between the aortic arch and the inferior pulmonary vein. Smoking and alcohol are the major risk factors and appear to have a synergistic effect in increasing incidence. It is more commonly seen in men.
- A 71 year old female with scleroderma undergoes a barium swallow examination. Which one of the following findings concerning the oesophagus would not be consistent with this diagnosis?
a. Oesophageal dilatation
b. Superficial ulcers
c. Hypoperistalsis in the upper third of the oesophagus
d. Stricture 5 cm above the gastro-oesophageal junction
e. Oesophageal shortening
- c. Hypoperistalsis in the upper third of the oesophagus
The oesophagus is the most commonly involved location of the gastro-intestinal tract in patients with scleroderma. Smooth muscle atrophy causes hypoperistalsis and eventually aperistalsis in the lower two-thirds of the oesophagus. The upper third of the oesophageal wall contains skeletal muscle and is therefore unaffected by the disease process.
- A 32 year old male is referred for a barium swallow by his GP due to dysphagia resistant to medical treatment. A smooth, lobulated, eccentric mass is seen in the middle third of the oesophagus containing foci of calcification. The diagnosis is most likely to be which one of the following?
a. Leiomyoma
b. Squamous cell carcinoma
c. Adenocarcinoma
d. Oesophageal web
e. Intramural pseudo diverticulosis
- a. Leiomyoma
Oesophageal leiomyoma is the most common benign submucosal tumour of the oesophagus, typically occurring in young men. The classical features of oesophageal leiomyoma include a smooth intramural mass in the lower or middle third of the oesophagus with intact overlying mucosa. It is the only tumour of the oesophagus that calcifies, although calcification is rare.
- A 67 year old man is referred for a barium swallow from the surgical outpatient department with a history of dysphagia to solids. A mid-oesophageal stricture is demonstrated. Which one of the following causes is unlikely to be in the differential?
a. Barrett’s oesophagus
b. Squamous cell carcinoma of the oesophagus
c. Schatzki ring
d. Caustic substance ingestion
e. Epidermolysis bullosa
- c. Schatzki ring
All are reasonable differentials for a mid-oesophageal stricture, albeit with varying degrees of frequency, with the exception of a Schatzki ring which is found in the lower oesophagus. It occurs near the squamocolumnar junction and is associated with reflux. It is non-distensible and best seen in the prone position on barium swallow examinations. Schatzki rings are often asymptomatic, but oesophageal dilatation may be required where dysphagia is severe.
- A 51 year old male patient has a barium swallow for the investigation of dysphagia. This shows a 10 cm tapered stricture in the mid oesophagus along with multiple fine linear projections perpendicular to the lumen, each 3–4mm long, in this segment. There are occasional 3ry contractions & mild GE reflux. What is diagnosis?
a. Chagas disease
b. Oesophageal intramural pseudo diverticulosis
c. Oesophageal varices
d. Cytomegalovirus infection
e. Oesophageal carcinoma
- b. Oesophageal intramural pseudo diverticulosis
Oesophageal intramural diverticulosis relates to dilated excretory ducts of the deep mucous glands of the oesophagus. They are best demonstrated on barium swallow and have the classical appearance as described in the question. The pseudodiverticular can appear to float outside the oesophagus when no communication with the lumen is seen. Most patients have dysphagia at presentation and associated conditions include diabetes, candida infection, esophagitis, stricture and alcohol abuse.
- A 29-year-old man presents with a 6-month history of dysphagia, associated with retrosternal pain. A barium swallow demonstrates a markedly dilated oesophagus containing food debris. There is a smooth narrowing of the distal oesophagus with barium intermittently spurting into the stomach. What is the most likely diagnosis?
A Oesophageal achalasia
B Oesophageal leiomyoma
C Paraoesophageal hiatus hernia.
D Peptic oesophageal stricture
E Squamous cell carcinoma of the oesophagus
A Oesophageal achalasia
Clinical features of oesophageal achalasia also include relief of retrosternal pain with carbonated and hot drinks (relaxes the lower oesophageal sphincter).
