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A 35 Years Old female with difficulty in swallowing liquid food with absent esophageal motility

This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here after collecting informed patient consent (form downloadable Click Here)  by BMJ Elective Student. 


The history below is translated from the original Bengali content in the patient's own voice:

1. I am 35 years old. Whenever I want to drink water it gets stuck in my throat and as a result, I can not drink water. Then after belching it passes down to stomach, and following that I get hyperacidity. I have a problem with hyperthyroidism. I have these problems since last 10 years.

2. I can not take fasting and cannot take food because of that.
3. I went to Hyderabad earlier in a city hospital, but they didn't prescribe many medicines and said that my upper part of the esophagus got narrowed. (Pantacid LA, Diaval liquid [?], Gelecase syrup [?]).
4. I have no other personal medical history. One of my brothers has low "bodh shokti' (couldn't make it translated). My both parents have hypertension.
5. I enjoy celebrating in different programs and enjoy taking food. I have no history of taking alcohol or any other illicit drugs.
6. I have no known history of any allergy.



ORIGINAL BANLA HISTORY:




Barium meal x-ray:



Comments

  1. VivekBMJstudent29 October 2018 at 10:35

    vivek: "Given that esophageal aperistalsis also occurs with disorders other than achalasia, including GERD, collagen vascular diseases, and diabetes, the diagnosis of achalasia is highly dependent on accurately detecting impaired LES relaxation. Assuming that the LES could be intubated, an inaccurate diagnosis of impaired relaxation could result from artifactual relaxation associated with inappropriate catheter design or from using suboptimal diagnostic thresholds. Two studies utilizing assemblies that control for the effect of axial movement (a sleeve sensor and high-resolution manometry with topographic analysis) were recently conducted to minimize such errors. The highlights of these studies are summarized in Table 1. With a sleeve sensor, the best single assessment of EGJ relaxation for a diagnosis of achalasia was mean relaxation pressure using the 95th percentile value of controls (12 mm Hg) as the upper limit of normal.32 Utilizing high-resolution manometry with topographic analysis, similar accuracy was achieved using a threshold value of 8–10 mm Hg for the lowest mean residual pressure in a 3-second postdeglutitive interval.34 However, the greatest accuracy was achieved utilizing a novel concept for assessing LES relaxation: the transsphincteric pressure gradient during the 2- to 6-second postswallow interval. Pressure gradients exceeding 5 mm Hg had a sensitivity of 94% and a specificity of 98% for detecting achalasia." https://www.gastrojournal.org/article/S0016-5085(04)02004-9/fulltext

    vivek: https://www.cghjournal.org/article/S1542-3565(16)31175-2/fulltext https://www.ncbi.nlm.nih.gov/pubmed/1425081?dopt=Abstract

    ReplyDelete
  2. VivekBMJstudent29 October 2018 at 10:36

    her problem could have been a result of corrosive strictures rather than Achalasia. Her detailed history suggests that she was in a period of grief having given up eating food for a few days after her grandma died and when she began eating she noticed that she couldn't swallow unless she was washing it down with water. Reading between the lines I suspect she may have swallowed a corrosive before that. Will try to elicit that history today taking her into a lot of confidence.

    How specific is intraesophageal manometry for Achalasia? Will need some review of literature around this

    ReplyDelete

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