Which of the following statement(s) is/are true concerning the diagnosis and management of the patient whose barium esophogram is shown in Figure 18-29?

c. Despite the impressive radiologic picture, passage of the endoscope through the area of narrowing will likely be possible

The x-ray demonstrates moderately advanced achalasia with a dilated esophagus with a narrowed tapering “bird’s beak” appearance of the distal esophagus. Achalasia is the best known primary motility disorder of the esophagus. It is characterized by failure of the esophageal body peristalsis and incomplete relaxation of the LES. It is generally thought to be caused by neuronal degeneration of the myenteric plexus of the esophageal wall, causing aperistalsis, and to loss of activity of the inhibitory neurons in the LES leading to incomplete relaxation. Patients with achalasia all have dysphagia, and most have regurgitation. Careful questioning is needed to distinguish the regurgitation from vomiting. Generally, it occurs during or at the end of a meal, and the material tastes bland rather than sour or bitter. Patients often have to leave the table to regurgitate, and are usually slow eaters. Endoscopy frequently reveals residual liquid or food in the esophagus. Unlike a stricture, the narrowing of the lower end permits the passage of the endoscope, usually with a characteristic “popping” sensation. In every patient with presumed achalasia, it is very important to view the cardia from below with the endoscope retroflexed, as a small infiltrating gastroesophageal tumor may otherwise be missed. Manometry is required to establish the diagnosis of achalasia. The classic features on stationary manometry are: 1) Elevated LES pressure; 2) Incomplete LES relaxation; 3) Absence of esophageal body peristalsis; and 4) Positive intraesophageal body pressure. Although reports concerning the use of 24 hr pH monitoring appear in the literature, excessive acid exposure is rare.