Typical findings of primary esophageal achalasia

    (a) Dilation of the esophagus. Dilated esophagus drooped to both sides of the spine.

    (b) Food remnant in the esophagus

    (c) Whitish coating of the mucosa caused by adhesion of the remained food inside of the esophagus and thickening of the mucosa

    (d) Functional stenosis of the esophago-gastric junction. Endoscope passes through the tight segment with some resistance.

    (e) Abnormal contraction of the esophagus. Simultaneous contraction is clearly observed.

    Initial Management 
    •∆+: Barium esophagram with “bird-beak”, aperistalsis, and poor emptying of barium 
    – Pneumatic dilation or surgical myotomy
    – Peroral endoscopic myotomy (POEM)  
    Clinical management of achalasia: current state of the art, Clin Exp Gastroenterol 2016; 9: 71–82         
    – Esophagectomy : “ end-stage ” achalasia characterized by megaesophagus or sigmoid esophagus and signify cant esophageal dilation and tortuosity 
    – Other methodes: Botulinum toxin or calcium channel blocker
    Vaezi MF et al  ACG Clincal Guideline: Diagnosis and Management of Achalasia 2013