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Barium swallow
20%
20/101
Endoscopy
63%
64/101
Manometry
13%
13/101
Myotomy
0%
0/101
Nifurtimox
2%
2/101
Select Answer to see Preferred Response
This patient presents with signs and symptoms concerning for achalasia (given his dysphagia and trouble swallowing solids and liquids in a progressive fashion), possibly due to Chagas disease (given his travel to South America). A barium esophagram is the next step in management and should precede endoscopy in patients with dysphagia and a broad differential diagnosis. Achalasia is a motor disorder of the distal esophagus resulting from degeneration of Auerbach plexus which causes failure of the lower esophageal sphincter to relax during swallowing. As a result, natural peristalsis is disrupted and the patient experiences dysphagia to solids and liquids (with liquids often being the most problematic). The condition has been associated with Chagas disease, where the parasitic amastigotes destroy ganglion cells. A barium esophogram is helpful in making the diagnosis and should reveal the classic bird's beak tapering at the esophageal sphincter. Other findings in Chagas disease include Romañas sign (swelling of the eye), a chagoma (localized swelling at the area of parasite entry), systemic symptoms (fever, fatigue, myalgias, and headache), myocarditis, arrhythmias, and encephalitis. The diagnosis can be confirmed with a blood smear, PCR, ELISA, or immunofluorescence and treatment can include benznidazole or nifurtimox. Incorrect Answer: Answer 2: Endoscopy would be indicated after a barium swallow is performed to first image the esophagus and give an overall picture of the anatomy. Answer 3: Manometry may be used to confirm a diagnosis of achalasia but should not be the next/initial step in management. Answer 4: Myotomy would be indicated after the diagnosis of achalasia has been confirmed with manometry. Answer 5: Nifurtimox is successful in treating Chagas disease which is caused by Trypanosoma cruzi and transmitted by the Reduviid bug. However, diagnosis should be made by blood smear before treating this patient. Bullet Summary: The most appropriate initial step in management in achalasia is a barium swallow.
4.3
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