Which of the following is the most appropriate step to take next in the management of this patient? Three weeks ago, you diagnosed a 66-year-old male patient as having dysphagia of new onset. Today, the patient returns to the clinic for a follow-up visit to receive the results of diagnostic testing. The results of a barium esophagogram are consistent with achalasia, and esophageal manometry reveals aperistalsis. The patient describes his symptoms as being moderate; he can tolerate food as long as he eats very slowly and does not lie down for at least 3 hours after meals. He rarely experiences symptoms when drinking liquids. He has lost 6 lb over the past 3 months.
A. Trial of long-acting nitrates B. Refer for surgical myomectomy C. Upper endoscopy D. Repeat manometry in 4 weeks, employing a promotility agent
Upper endoscopy-key concept/objective: to understand the need to rule out pseudoachalasia in patients with suspected achalasia all patients suspected of having achalasia should undergo upper endoscopy to exclude pseudoachalasia arising from a tumor at the gastroesophageal junction. signs and symptoms of pseudoachalasia may mimic those of classic achalasia, both clinically and manometrically. the diagnosis of pseudoachalasia should be suspected in patients of older age, those with a short duration of symptoms, and those with more significant weight loss. in patients with achalasia, at endoscopy, the esophageal body often appears dilated and tortuous. retained secretions and food debris may be encountered. the region of the lower esophageal sphincter usually appears puckered and remains closed with air insufflation; however, with gentle pressure, the endoscope will transverse this area. the gastroesophageal junction and gastric cardia need to be examined closely for the presence of tumors to rule out pseudoachalasia.