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 non-contributory. Evaluation of her upper Gl 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.

The case of the 71-year-old female described above presents a clinical picture consistent with achalasia, a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and loss of esophageal peristalsis. Below, we address the specific components of the question, including diagnosis, confirmatory testing, and management strategies, with a focus on clinical geriatrics.

Likely Diagnosis

The likely diagnosis is achalasia. This is supported by the patient's symptoms and diagnostic findings:

1. Clinical Symptoms:
   • Progressive dysphagia for both solids and liquids.
   • Non-bilious projectile vomiting of undigested food and saliva.
   • Sensation of food sticking in the throat.
   • Significant unintentional weight loss (8 kg over six months).
2. Diagnostic Imaging and Endoscopic Findings:
   • Upper GI endoscopy: Dilated esophagus with pooling of saliva and tight gastroesophageal (GE) junction.
   • Barium swallow study: Demonstrated dilated esophagus with "bird beak" appearance, a classic radiological hallmark of achalasia.

These findings point toward impaired LES relaxation and esophageal stasis, hallmark features of achalasia.

Test to Confirm the Diagnosis

The gold standard test to confirm achalasia is esophageal manometry. This study measures the pressure dynamics of the esophagus and LES and typically reveals:

1. Impaired LES relaxation: Incomplete relaxation of the LES in response to swallowing.
2. Aperistalsis: Absence of coordinated peristalsis in the esophageal body.
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