Achalasia and tertiary waves

Case contributed by Frank Gaillard



Patient Data

Age: Adult

This patient with achalasia demonstrates prominent tertiary waves and poor / absent relaxation of the lower esophageal sphincter.

Case Discussion

A barium swallow is able to confirm that:

  • bird beak sign
  • esophageal dilatation
  • pooling or stasis of barium in the esophagus when the esophagus has become atonic or non-contractile (a late feature in the disease)
  • incomplete lower esophageal sphincter relaxation that is not coordinated with esophageal contraction
  • failure of normal peristalsis to clear the esophagus of barium when the patient is in the recumbent position, with no primary waves identified
  • uncoordinated, non-propulsive, tertiary contractions 
  • when barium column is high enough (patient standing) the hydrostatic pressure can overcome the lower esophageal sphincter pressure allowing passage of esophageal content

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