Pseudoachalasia

Pseudoachalasia is achalasia-pattern dilatation of the oesophagus due to the narrowing of the distal oesophagus from causes other than primary denervation. One of the most common causes is malignancy (often submucosal gastric cancer) with extension in the lower oesophagus. The clinical and imaging similarities of achalasia and pseudoachalasia pose a differential dilemma, usually requiring further investigation.

The clinical course of pseudoachalasia depends on the underlying cause however it, in particular if secondary to the neoplasm, is usually short (<6 months) unlike the chronic clinical history in patients with primary achalasia. Patients also tend to be older (>50 years) than those with primary achalasia.

Aetiology
  • oesophageal malignancy
  • central and peripheral neuropathy
    • brainstem stroke
    • brainstem infiltration, e.g. malignancy, amyloidosis
    • infiltration of vagus by malignancy
    • complication of bilateral vagotomy
    • chronic idiopathic intestinal pseudoobstruction
    • diabetes mellitus
    • paraneoplastic 
  • oesophageal stricture
    • ischaemia
    • reflux
    • acid/alkali ingestion
  • scleroderma
    • the patulous esophagus in some presentations of scleroderma may lead to chronic severe reflux and development of a distal oesphageal stricture
    • this patient population is also at risk for oesophageal carcinoma

The pathophysiology of pseudoachalasia is thought to be twofold

  • obstruction of the lower oesophagus due to tumour proliferation
  • tumour infiltration, denervation, or nerve malfunction of the neuromyenteric plexus (of Auerbach) thus creating functional obstruction similar to achalasia

Although less common, it is possible for primary achalasia and malignancy to coexist.

The plain chest film and barium swallow findings are similar to achalasia and may also show other features of the underlying cause (listed above).

Two useful discriminators in barium swallow, particularly in cases secondary to underlying neoplasm, are

  • more marked mucosal irregularity of malignant lesions in pseudoachalasia
  • the temporary patency of lower oesophageal sphincter if the hydrostatic pressure is increased in achalasia

Computed tomography is usually the imaging modality of choice for equivocal cases because it would more clearly depict a malignant lesion, as well as potential lymph node involvement, local invasion, or metastatic spread.

Oesophageal pathology
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Article information

rID: 20000
Section: Pathology
Synonyms or Alternate Spellings:
  • Achalasia pattern
  • Secondary achalasia
  • Achalasia pattern- differential
  • Achalasia like
  • Pseudoachalasia
  • Achalasia pattern (differential)

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