AANP Family Nurse Practitioner (FNP) Certification ExamDiagnosisHard
A 60-year-old male presents with a 6-month history of progressive difficulty swallowing solids and liquids. He reports frequent regurgitation of undigested food, occasional nocturnal cough, and significant weight loss. He denies heartburn or abdominal pain. Barium swallow shows a 'bird's beak' appearance of the distal esophagus, and manometry reveals aperistalsis of the esophageal body and incomplete relaxation of the lower esophageal sphincter (LES). What is the most likely diagnosis?
- AAchalasia
- BEsophageal cancer
- CGastroesophageal Reflux Disease (GERD)
- DEsophageal stricture
Show answer & explanationAnswer & explanation
Correct answer: A. Achalasia
The patient's progressive dysphagia for both solids and liquids, regurgitation of undigested food, weight loss, and the classic 'bird's beak' appearance on barium swallow, combined with manometry findings of aperistalsis and incomplete LES relaxation, are pathognomonic for achalasia.
Why the other options are wrong
- B. Esophageal cancer can cause progressive dysphagia and weight loss, but typically for solids first, and would not show the specific manometry and 'bird's beak' findings of achalasia. While it's a differential, the classic findings strongly point to achalasia.
- C. GERD typically presents with heartburn, acid regurgitation, and often responds to acid suppression, which is not described. Dysphagia in GERD is usually for solids only due to stricture, not both liquids and solids due to motility issues.
- D. Esophageal stricture would cause progressive dysphagia, primarily for solids, but would not present with aperistalsis or incomplete LES relaxation on manometry, nor a bird's beak appearance.
Achalasia
A rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and loss of peristalsis in the esophageal body, leading to difficulty swallowing.
- Presents with progressive dysphagia for both solids and liquids.
- Common symptoms include regurgitation of undigested food and weight loss.
- Diagnosis confirmed by barium swallow ('bird's beak') and esophageal manometry (aperistalsis, incomplete LES relaxation).
Memory trick: Achalasia: 'A'll 'C'annot 'H'ave 'A' 'L'iquid 'A'nd 'S'olid 'I'ngestion 'A't once.