Difficulties in the diagnosis of pseudoachalasia

We undertook this study to determine the utility of various clinical findings and tests in the diagnosis of pseudoachalasia.

We reviewed the clinical, endoscopic, esophagographic, CT, and manometric findings of five patients with pseudoachalasia of malignancy. These patients were identified from our large group of 206 patients with manometrically diagnosed achalasia who were seen over the past 8 yr. For each pseudoachalasia patient, the two consecutively seen patients with idiopathic achalasia were chosen to comprise a control group.

The pseudoachalasia patients, as compared to the control group, had shorter duration of dysphagia (9.6 +/- 8.6 months vs 54.3 +/- 44.2 months, p < 0.05). They had similar weight loss (15.6 +/- 12.8 lbs vs 14.3 +/- 18.4 lbs, p = NS), but weight loss/time, where time is months of symptoms, was greater in the pseudoachalasia group (1.8 +/- 1.8 lbs/month vs 0.5 +/- 0.5 lbs/month, p < 0.05). There was, however, substantial overlap between the groups in all these parameters. Barium esophagography failed to reveal cancer in any of the pseudoachalasia patients. There was difficult passage of the endoscope through the gastroesophageal junction in all patients with pseudoachalasia, but endoscopic biopsy diagnosed cancer in only two of them. CT scans gave no clear evidence of malignancy in any patient, although three scans had nonspecific findings that, in retrospect, probably indicated malignancy. There were no distinguishing manometric findings.

When pseudoachalasia is suspected on the basis of a constellation of findings, such as advanced age, rapid weight loss, and difficulty in passing the endoscope through the gastroesophageal junction of a nondilated esophagus, negative findings on biopsy and CT scans should not lead to a false reassurance of a benign disorder, and repeated biopsy and scans or surgical exploration may lead to the diagnosis of pseudoachalasia.