Under usual manometric conditions, esophageal achalasia is confirmed, provided the conditions are a dry swallow and an empty esophagus.

Is dry swallow a proper stimulus in a disease where the link between deglutition and motor response is impaired?
Is an empty esophagus typical in these patients?

It seemed more realistic to explore the pressures when filling an empty esophagus without or with acetyl-beta-methylcholine.

Techniques

In order to explore entirely the inferior sphincter, six open-tip catheters, one centimeter apart, were needed. 58 patients with so-called achalasia were studied. Acetyl-beta-methylcholine was injected with a small dosage producing no effect when the esophagus was empty.

Results

In 84% of the patients, as the body of the esophagus was progresively filled, the pressure did not rise only inside the body, but also inside the sphincter, remaining higher in the sphincter that in the body, up to 50 millibars, at which point the pressures became equal.

This reversal of the normal reaction of the sphincter may be called “reactive spasm”. On emptying the body, pressures returned to normal both in the body and in the sphincter, but after a delay of several seconds in the sphincter.

The site of the reactive spasm was the upper end of the sphincter and the sphincter seemed to lengthen proximally, provided an appropriate catheter was used. This was confirmed by simultaneous cineradiography and manometry.
After succesful Heller operations, the reactive spasm disappeared.

After giving a small dose of Acetyl-beta-methylcholine, the reactive spasm was strikingly increased, both in the sphincter lengthening proximally and in the body: The chemical stimulus sensitized the esophagus to the mechanical stimulus, confirming the law of denervation outlined by Claude Bernard and confirmed by Cannon.

The bougie exerts a pressure of around 75 millibars, higher than the resistance of the sphincter (around 50 millibars)

Conclusion

Achalasia, as a phenomenon, is an artifact of the conditions of manometry.
Its value as an explanation of the dysphagia or as a name for the disease is questionable.
The proper explanation is the reactive spasm and the name of the disease may remain mega-esophagus or become esophageal plexatrophy.

- Besançon F:
Technical changes leading to a new theory to replace esophageal achalasia.
Am J Dig Dis 1968; 13 (4): 361-367
- Besançon F, Janin B, Debray C:
Physiopathologie du méga-œsophage. Le cardiospasme réactionnel.
Arch Mal App Dig 1962; 51: 1543-1555
- Besançon F, Janin B, Debray C:
Le méga-œsophage, cardiospasme réactionnel. Données électromanographiques et cinéradiométriques.
Sem Hôp 1962; 38: 1555-1564