Achalasia – barium swallow

This 32 year old woman was referred for a barium swallow because of progressive dysphagia. This image shows the typical appearances of oesophageal achalasia, with a dilated oesophagus tapering abruptly at the level of the lower oesophageal sphincter and resulting in the classic ‘bird’s beak’ sign (arrow). Barium swallow will usually also show uncoordinated oesophageal contractions in these patients. The diagnosis of achalasia requires manometry for confirmation; indeed, in a significant proportion of patients with achalasia the barium swallow study will be normal, so if you suspect it clinically remember that a normal barium swallow is not sufficient to exclude the diagnosis. The differential diagnosis for this appearance on a barium swallow includes malignancy (also referred to as ‘pseudoachalasia’), hence the importance of endoscopic correlation.