Achalasia: Findings on Fluoroscopy with Barium Swallow

Achalasia: Findings on Fluoroscopy with Barium Swallow
Authors: Nameerah Wajahat, Omer Mansoor, Aly Valji Reviewers: Tara Shannon, Reshma Sirajee, Stephanie Nguyen* *MD at time of publication
Barium swallow performed (patient swallows barium contrast, a radiopaque agent, which outlines the gastro-intestinal (GI) tract during fluoroscopy)
Primary Achalasia
Secondary (Pseudo) Achalasia
(due to another disease process such as tumor, Chaga’s disease, diabetes mellitus)
Secondary disease processes can cause denervation or nerve dysfunction of esophageal myenteric plexus (EMP). Tumors can obstruct the lumen and infiltrate the EMP.
Visual differences from primary achalasia
Look for fixed abnormalities and/or mucosal irregularities and shouldering in the setting of a tumor
Nerves controlling the lower esophagus are damaged, making it difficult for food and liquids to pass the esophagus
See “Achalasia: Pathogenesis and Clinical Findings” for full pathogenesis of primary and secondary achalasia
Inflammation and degeneration of nerves in the wall of esophagus
Dysfunction of the esophageal myenteric plexus (network of nerves in the GI tract responsible for peristalsis and sphincter relaxation)
Incomplete relaxation of the Loss of peristalsis in distal lower esophageal sphincter (LES) esophagus
Barium has difficulty passing through the LES to the stomach
Barium outlines the GI tract, following esophageal abnormalities
Normal findings
Esophageal Dilatation
Occurs upstream of narrow LES
Bird Beak Sign / Rat Tail Sign
Smooth narrowing of the distal esophagus
Incomplete LES relaxation
Barium Swallow may be normal in some patients with achalasia. Esophageal manometry (gold standard for diagnosis) or upper endoscopy can be considered instead.
Image Source: Radiopaedia
Radiographic Findings
Published November 9, 2022 on