Step 1: View clinicals

A 52 year old woman presents with slowly worsening, intermittent 'burning' chest pain for 1 year. There is no radiation, and the pain is not exacerbated by exertion. She was prescribed a two-week course of Omeprazole by her primary care physician approximately a month ago. However, her symptoms remained unchanged. Close questioning reveals the presence of mild dysphagia to both solids and liquids, for several months, which was mainly felt in the upper chest. She also lost 5 kg of weight during the past half-year. Her medical history is significant for uncomplicated mild hypertension for 4 years, which is well controlled on Amlodipine 10 mg daily. No other comorbidities are present. She has never smoked, and only drinks socially. A complete blood count, two 12-lead ECGs, and an exercise stress test have been ordered recently, all of which were normal.

Step 2: Order all relevant investigations

Upper GI Endoscopy

The esophagus appears normal. The gastroesophageal junction is difficult to traverse and only opens after multiple attempts. The stomach and duodenum appear normal.

Esophageal Manometry

There is impaired relaxation of the lower esophageal sphincter (LES), during deglutition. The basal esophageal pressure is 62 mmHg (normal: < 45). There is aperistalsis in the distal two-thirds of the esophagus.

Barium Swallow

The barium swallow shows hold up of barium at the gastroesophageal junction.

CT Abdomen

The CT scan of the abdomen appears completely normal.

Step 3: Select appropriate management

Calcium Channel Blockers
Graded Pneumatic Dilatation
Botulinum Toxin Injection

Score: ★★☆