Q1. Correct answer: D
Rationale
Achalasia and pseudoachalasia are on the differential. Given the advanced age, progressive course, and significant weight loss, an endoscopy with careful attention to GEJ should be performed to rule out malignancy causing a pseudoachalasia presentation (answer D). Manometry should be done after the endoscopy to confirm and subtype the achalasia. If achalasia is confirmed and malignancy is ruled out, myotomy either with a modified Heller approach or peroral endoscopic myotomy would be appropriate in a surgically fit patient (answer A) and botulinum toxin may be considered in a poor surgical candidate. Medications such as calcium channel blockers and nitrates (answer C) are not definitive treatment options for achalasia and not warranted in malignancy. Additional information is needed on the diagnosis and prognosis prior to committing to a G tube (answer E).
Reference :
Zaninotto G., Bennett C., Boeckxstaens G., et al. The 2018 ISDE achalasia guidelines. Dis Esophagus. 2018 Sep 1;31(9).
