A 45-year-old woman was referred for evaluation of longstanding dysphagia to both
solids and fluids, and progressive regurgitation over the past 10 years. Besides glycogenic
acanthosis, upper gastrointestinal endoscopy was suggestive of esophageal dilation
with a hypomotile contraction pattern. During careful observation with air insufflation,
the narrowed esophagogastric junction failed to relax but could be passed easily,
giving rise to a popping sensation ([Fig. 1]). Likewise, on retroflexion the cardia appeared tight, with discrete tongues extending
from the squamocolumnar junction ([Fig. 2]). To better assess the endoscopic characteristics of the presumed achalasic cardia,
we carried out a thorough dynamic retroflexed examination with different levels of
scope insertion. In contrast with the close-up view, the esophagogastric junction
sleeve flattened while advancing the endoscope, and the squamocolumnar junction was
pulled out to come into full view ([Fig. 3]). This was reproducible on repetitive “to-and-fro” scope maneuvers, with the squamocolumnar
junction swinging in and out of endoscopic view ([Video 1]). The diagnosis of esophagocardiac achalasia was established by manometry, which
confirmed resting lower esophageal sphincter (LES) hypertension > 60 mmHg with lack
of swallow-induced relaxation and low-amplitude simultaneous esophageal body contractions.
The patient subsequently underwent uncomplicated pneumatic balloon dilation (30 mm
Rigiflex II Single Use Achalasia Balloon Dilator; Boston Scientific, Ratingen, Germany).
Fig. 1 Endoscopic view of the distal esophagus in a 45-year-old woman with long-standing
dysphagia and progressive regurgitation showing a narrowed esophagogastric junction.
Fig. 2 Standard retroflexed view of the tight-fitting cardia with discrete tongues of the
squamocolumnar junction.
Fig. 3 Maintained retroflexed view on deep scope insertion with the squamocolumnar junction
coming into full view.
Given that current practice trends in most countries prioritize upper gastrointestinal
endoscopy in the diagnostic algorithm for patients with presumed esophageal dysphagia,
the endoscopist should be aware of features suggestive of achalasia so as to avoid
misdiagnosis, e. g., with strictures of peptic origin [1]. The clinical significance of endoscopy in achalasia is largely to rule out malignant
pseudo-achalasia [2]. Despite endoscopy being negative in an estimated 40 % – 50 % with less advanced
or atypical motor disease, positive recognition of endoscopic achalasia characteristics
is essential in stratifying patients for dedicated diagnostic work-up and treatment
decisions [3]. The Identification of potential novel endoscopic markers of esophagocardiac achalasia,
such as the as-yet unreported phenomenon of the “swinging” squamocolumnar junction,
most likely reflecting resting LES hypertension, might be helpful in timely referral
for specialized motility testing. However, the diagnostic accuracy of this endoscopic
finding and its correlation with manometric findings warrants further assessment in
systematic studies, e. g., by blinded videotape review.
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AH
The squamocolumnar junction swinging in and out of endoscopic view on repetitive
“to-and-fro” scope maneuvers.
