Dysphagia to solids AND liquids, regurgitation
Start: Barium esophagram (bird-beak, dilated above)
Then: EGD (exclude pseudoachalasia/malignancy)
Most accurate: Manometry (↑LES pressure, absent peristalsis)
Treat: Pneumatic dilation / Heller myotomy / POEM; botox or nitrates if poor surgical candidate
Order set
- Barium swallow
- Upper endoscopy
- Manometry
Criteria
AdmitSevere dysphagia/aspiration, procedure complication
DischargeNutrition adequate, definitive therapy planned
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Weight loss
- Progressive dysphagia (exclude cancer)
Differentials
- Pseudoachalasia (malignancy)
- Diffuse esophageal spasm
- Stricture
Common mistakes
- Missing malignant pseudoachalasia
- Skipping endoscopy
Disposition & follow-up
Pneumatic dilation/myotomy/POEM referral.
Discharge package
Medications—
Follow-upGastroenterology; post-procedure review
LifestyleEat upright, small meals
Warning symptomsWorsening dysphagia, weight loss, regurgitation
💊 Treatment detail — doses & preparation
Pneumatic dilation / POEMdefinitive
DoseGraded balloon dilation (30–40 mm) or per-oral endoscopic myotomy
PreparationPost-dilation gastrografin to exclude perforation
MonitorChest pain/fever = perforation watch
Nifedipine (bridge)temporary
Dose10–20 mg SL before meals — short-term LES relaxation while awaiting definitive
Preparation5/10 mg capsules
MonitorHypotension; effect wanes
📖 ACG AchalasiaReviewed July 2026