Which clinical features are most characteristic of achalasia?

• A. Dysphagia to solids and liquids with regurgitation; birds beak on barium swallow
• B. Heartburn and regurgitation only
• C. Epigastric pain after meals without dysphagia
• D. Nausea without dysphagia or regurgitation

Answer: (A)

Achalasia occurs when the lower esophageal sphincter fails to relax and there is a loss of normal esophageal peristalsis, creating a functional obstruction at the gastroesophageal junction. Because the esophagus cannot effectively propel food and the LES remains constricted, patients develop dysphagia to both solids and liquids from the start. Regurgitation of undigested meals is common and can occur at night, helping distinguish this from simple reflux. On imaging, the dilated esophagus meets a narrowed distal segment, producing the characteristic “birds beak” sign on a barium swallow. This combination of dysphagia to both solids and liquids, regurgitation, and the classic radiographic finding is what makes achalasia most likely.

The other presentations don’t fit as well: heartburn and regurgitation without the functional obstruction point toward GERD; epigastric pain after meals without dysphagia suggests dyspepsia or peptic disease; nausea without dysphagia or regurgitation is nonspecific and not characteristic of achalasia.