Syndrome of Vigorous Achalasia: Clinical and Physiologic Observations

Vigorous achalasia is an esophageal disorder manifesting clinical and x-ray characteristics of achalasia and diffuse spasm. Since 1956, 88 of more than 5,800 patients referred to the Mayo Clinic for esophageal motility tests have been diagnosed as having vigorous achalasia. Sixteen cases were excluded as not representative or as showing some peculiarities. Thus, 72 cases form the basis of this report. The patients ranged in age from 12 to 79 years. All but one had dysphagia, 56 had regurgitation, and 51 had pain. Cardiospasm, dilatation, and diffuse spasm were the most common of the roentgenologic interpretations. Esophageal motility studies were obtained in all cases, and pressure-detecting units were passed into the stomach in 68 cases. The orderly relaxation and contraction of the gastroesophageal sphincter observed in health after swallowing were not observed. Relaxation was absent or poor in all cases, and only one patient had normal contraction of the sphincter. All patients developed high esophageal pressures during the simultaneous contractions. No peristalsis was detected. Resistance to the passage of a sound felt to the examiner like achalasia in ten of 14 cases and more like diffuse spasm in four. Endoscopy, performed in 32 cases, suggested achalasia in 11 and spasm in three; results were normal in eight cases and suggested other lesions in the remaining ten. Treatment consisted of simple dilatation (eight cases), hydrostatic dilatation alone (ten cases), a modified Heller myotomy alone (40 cases), and a combination of the last-named procedures (seven cases). Seven patients were not treated at this clinic. Surgical treatment by the modified Heller myotomy was more effective than hydrostatic dilatation.