Diagnosis of primary versus secondary achalasia: Reassessment of clinical and radiographic criteria

OBJECTIVE. Our purpose was to reassess the usefulness of barium studies and various clinical parameters for differentiating primary from secondary ach alasia. MATERIALS AND METHODS. Radiology files from 1989 through 1999 revealed 29 p atients with primary achalasia and 10 with secondary achalasia (caused by c arcinoma of the esophagus in three, of the gastric cardia in three, of the lung in three, and of the uterus in one) who met our study criteria. The ra diographs were reviewed to determine the morphologic features or the narrow ed distal esophageal segment and gastric cardia and fundus, Medical records were also reviewed to determine the clinical presentation; endoscopic, man ometric, and surgical findings; and treatment. RESULTS. The mean patient age was 53 years in primary achalasia versus 69 y ears in secondary achalasia (p = 0.03). The mean duration of dysphagia was 4.5 years in primary achalasia versus 1.9 months in secondary achalasia (p < 0.0001). The narrowed distal esophageal segment had a mean length of 1.9 cm in primary achalasia versus 4.4 cm in secondary achalasia (p < 0.0001), and the esophagus had a mean diameter of 6.2 cm in primary achalasia versus 4.1 cm in secondary achalasia (p < 0.0001). The narrowed segment was eccen tric or nodular or had abrupt proximal borders in only four of 10 patients with secondary achalasia, and evidence of tumor was present in the gastric fundus in only three. CONCLUSION. When findings of achalasia are present on barium studies. a nar rowed distal esophageal segment longer than 3.5 cm with little or no proxim al dilatation in a patient with recent onset of dysphagia should be conside red highly suggestive of secondary achalasia, even in the absence of other suspicious radiographic findings.