A 71-year-old female with longstanding history of episodic non-bilious projectile vomiting (mostly undigested food and saliva) presented with worsening of her symptoms and food intolerance during the previous six months. Over that time frame, she noted a sensation of food becoming stuck in her throat and progressive difficulty swallowing. This difficulty was initially related to solids and then progressively to liquids, which severely limited her food intake. She lost 8 kg since the symptoms started to worsen. She stays alone and does not smoke or drink alcohol. Her family history is noncontributory. On evaluation her upper GI endoscopy showed dilated esophagus and pooling of saliva and a tight GE junction. The barium swallow demonstrated dilated mid-distal esophagus with “bird beaking” appearance. Questions: What is the likely diagnosis? What test is needed to confirm the diagnosis? Outline the common modalities of management. 

Based on the presented symptoms and diagnostic findings, the likely diagnosis for this patient is achalasia.

Achalasia is a rare esophageal motility disorder that affects the ability of the esophagus to move food down to the stomach. It occurs due to the degeneration or dysfunction of the neurons in the esophageal wall responsible for peristalsis (rhythmic contractions) and relaxation of the lower esophageal sphincter (LES), leading to impaired emptying of food from the esophagus into the stomach. This results in the accumulation of food and liquid in the esophagus, leading to dysphagia, regurgitation, and eventually, aspiration.

The hallmark symptom of achalasia is dysphagia, which typically begins with solids and then progresses to liquids. Patients may also experience regurgitation of undigested food, non-bilious vomiting, weight loss, chest pain, heartburn, and a sensation of food getting stuck in the throat. The symptoms of achalasia may develop gradually and worsen over time, which can lead to malnutrition, dehydration, and respiratory complications.

The diagnosis of achalasia is made based on a combination of clinical symptoms and objective findings. Upper gastrointestinal endoscopy may show dilated esophagus with retained food or saliva, and a tight lower esophageal sphincter. The barium swallow test may show a dilated esophagus with a characteristic "bird beak" appearance, indicating ___ ___ ______ ____ ________ _______ __________ __________ ______ _________ ___ ______.
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