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.
- oesophageal malignancy
- central and peripheral neuropathy
- acid/alkali ingestion
- 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 dysmotility
- oesophageal tumours
- benign oesophageal neoplasms
- malignant oesophageal neoplasms
- gastro-oesophageal reflux disease
- oesophageal stricture
- 1. Dodds WJ, Stewart ET, Kishk SM et-al. Radiologic amyl nitrite test for distinguishing pseudoachalasia from idiopathic achalasia. AJR Am J Roentgenol. 1986;146 (1): 21-3. AJR Am J Roentgenol (citation) - Pubmed citation
- 2. Kahrilas PJ, Kishk SM, Helm JF et-al. Comparison of pseudoachalasia and achalasia. Am. J. Med. 1987;82 (3): 439-46. Am. J. Med. (link) - Pubmed citation
- 3. Liu W, Fackler W, Rice TW et-al. The pathogenesis of pseudoachalasia: a clinicopathologic study of 13 cases of a rare entity. Am. J. Surg. Pathol. 2002;26 (6): 784-8. Am. J. Surg. Pathol. (link) - Pubmed citation
- 4. Robertson CS, Griffith CD, Atkinson M et-al. Pseudoachalasia of the cardia: a review. J R Soc Med. 1988;81 (7): 399-402. - Free text at pubmed - Pubmed citation
- 5. Ogilvie H. The early diagnosis of cancer of the oesophagus and stomach. Br Med J. 1947;2 (4523): 405-7. - Free text at pubmed - Pubmed citation
- 6. Lawson TL, Dodds WJ. Infiltrating carcinoma simulating achalasia. Gastrointest Radiol. 1976;1 (3): 245-8. - Pubmed citation
- 7. Eisenberg RL. Gastrointestinal radiology, a pattern approach. Lippincott Williams & Wilkins. (2003) ISBN:0781737060. Read it at Google Books - Find it at Amazon
- 8. Fauci AS, Braunwald E, Kasper DL et-al. Harrison's Manual of Medicine. McGraw-Hill Professional. (2009) ISBN:0071477438. Read it at Google Books - Find it at Amazon