Manometric schematic of achalasia demonstrating aperistaltic contractions, increased intraesophageal pressure and failure of relaxation of the lower esophageal sphincter.

Barium swallow. Dilated esophagus with retained column of barium and "bird's beaking" suggestive of achalasia

A transverse CT image showing marked dilatation of the esophagus.

My goal in writing this is to provide information for others with Achalsia My favorite medical image is a series of digital x-ray images of my esophagus. I have had difficulty swallowing food (dysphagia) for about ten years. Occasionally, I'll get some food "stuck" in my esophagus and over the years this became more frequent and more severe. In 2014, I was diagnosed as having achalasia, which is a neurodegenerative disease within the neurons that control the esophagus (myenteric plexus). The disease causes the lower esophageal sphincter (LES), which is a gateway between the esophagus and stomach, to stay closed more than it should. The result is that the movement of food by waves of muscle action is impaired. The causes of achalasia remain unknown, although it may be an auto-immune disease. There is no cure for achalasia. However, there are effective treatments. I had several diagnostic tests to deduce that I had achalasia. The most important test was a timed barium swallow x-ray. In this test, I am standing laterally to the X-ray beam, which is illuminating most of my thoracic cavity, which after passing through my body, projects a 2D representation onto a digital detector. The timed barium test is performed by rapidly swallowing about 100 mL of barium in solution and then using a series of X-rays at 1, 2 and 5 minutes to monitor the progress of the barium liquid through my digestive system. The barium is opaque to the high energy X-ray photons while the rest of the tissue is much less opaque. Figure 1a is a "scout" image captured just prior to the barium swallow. Figure 1b shows the progress of the barium after one minute. There is a large quantity of barium that remains in my upper esophagus, with a significant narrowing in the lower esophagus along with some undesirable oscillations in my lower esophagus. In Figure 1c, after two minutes, there is still significant barium in my esophagus. The conclusion from radiologist Dr. Sarah Menashe was: "Severe esophageal dysmotility as described with marked delay in esophageal emptying..." As a result of the timed barium tests and an investigative endoscopy, my thoracic surgeon, Dr. Brian Louie, recommended surgery as a treatment that would help improve my dysphagia. Dr. Louie suggested using a procedure developed in the last few years: Peroral Esophageal Myotomy (POEM). In this surgery, Dr. Louie operates using an endoscope to cut some of the muscle fibers in the esophagus, which causes the LES to open more readily In January 2015, Dr. Louie performed POEM on me. A couple of important questions to answer after the surgery. First, are there any leaks in my esophagus? Next, did the surgery work? The key test for this was another set of timed barium images of my esophagus. Figure 1d is a scout image; I have circled the area of the surgical incision; there are five temporary clips in this area to close off the incision. Figure 1e shows the barium progress after one minute; there is still a quantity of barium pooled in the esophagus. Figure 1f, after 1.2 minutes, shows that most of the barium exited to the stomach. Overall, the conclusion by my radiologist, Dr. Timothy Gleason was: "There is no leak." The question of how effective the treatment is requires monitoring over time. My next timed barium test is on 15 October. Also, I now have annual endoscopic observations to monitor my esophagus as I am more susceptible to some diseases. From a patient standpoint, I can say that this treatment has significantly improved my quality of life. However, the timed barium X-ray provides a more quantitative assessment of how my esophagus functions. AchalasiaEdit

Esophageal cancer as shown by a filling defect during an upper GI series

Esophageal stent for esophageal cancer

Diagram showing T1,T2 and T3 stages of oesophageal cancer.