Asymptomatic Achalasia cardia presenting with bilateral bronchiectasis Shahul Hameed Aboobackar1,  Aswini Kumar Mohapatra2, Manu Mohan K3 1 Post graduate student, 2 Professor, 3 Associate Professor,   Department of Pulmonary Medicine, Kasturba Medical College Manipal, Manipal University, Manipal, Karnataka, India Abstract Figure 1 A 25-year-old female presented with chronic expectorative cough and breathlessness. On evaluation, she was found to have bilateral bronchiectasis with achalasia cardia. However, the patient denied any history of dysphagia, regurgitation and heart burns. Bronchiectasis is an established complication of achalasia cardia. However, asymptomatic achalasia cardia presenting with symptomatic bronchiectasis is rare. Introduction Figure 2 Achalasia is a disorder of oesophageal motility characterised by aperistalsis of oesophageal body, and impaired relaxation of lower oesophageal sphincter. Most cases of Achalasia are symptomatic and usually present with dysphagia, nasal regurgitations and heart burns. The oesophageal dysmotility can predispose to repeated aspirations, resulting in recurrent pneumonias and bronchiectasis. We present a case of asymptomatic achalasia cardia which presented initially as a pulmonary complication. Asymptomatic achalasia presenting with bilateral bronchiectasis is extremely rare. History Outcome 25-year-old female. Chronic expectorative cough and exertional shortness of breath since 10 years with recent aggravation. Profuse, purulent, yellow, often foul smelling expectoration. High grade fever with chills of 3 days duration. No loss of appetite or recent weight loss. Multiple hospital admissions for recurrent pneumonias in the past. No past history of pulmonary tuberculosis. No congenital anomalies in the family. No addictions. Patient was advised to undergo Heller’s myotomy, in view of young age, in order to prevent further lung damage. Patient was not willing for surgery. Advised to lie down in propped up position and to avoid lying down immediately after meals. Patient continued to be symptomatic during followup. Discussion Achalasia is a disorder of esophageal motility characterised by aperistalsis of esophageal body, hypertensive lower esophageal sphincter (LES) and impaired relaxation of LES. Impaired esophageal emptying with resistance to antegrade flow. Esophagus becomes elongated and dilated. Most patients are symptomatic. Dysphagia is the cardinal symptom (90% cases). Chest discomfort, regurgitation, weight loss are other symptoms. Diagnosis made using barium swallow and confirmed by esophageal manometry. CT Thorax is not routinely required for diagnosis. Achalasia can be easily diagnosed and treated in symptomatic patients. Treatment options include pharmacotherapy with nifedipine and balloon esophageal dilatation. Heller’s myotomy is the definitive procedure of choice. Surgery is curative and has good prognosis. Asymptomatic achalasia presenting due to its pulmonary complications is rare. Treatment has to be instituted early so as to prevent any further lung damage. Physical examination General physical examination was normal. Respiratory system examination revealed bilateral diffuse coarse crepitations. Examination of other systems did not reveal any abnormality. Investigations Routine blood investigations were normal. Chest radiograph showed bilateral bronchiectatic changes, predominantly over the right mid-zone and left lower zone. (Figure1) Sputum Ziehl-Neelsen staining for acid fast bacilli was negative. High resolution computerised tomography (HRCT) of thorax revealed cystic bronchiectasis involving right upper lobe and middle lobe segments, left lingular segments and anterior medial basal segment of left lower lobe, along with dilatation of the entire extent of esophagus and smooth narrowing at gastroesophageal junction. (Figure 2) Upper gastrointestinal endoscopy showed inflammatory changes with minimal ulcerations along the lower esophagus. Barium swallow study showed dilated thoracic oesophagus with narrowed gastroesophageal junction. Oesophageal manometry showed high pressure at the level of lower oesophageal sphincter and confirmed aperistalsis along the lower esophagus. References Reynolds JC, Parkman HP, Achalasia. Gastroenterol Clin North Am 1989; 18:223-55. Muralidharan S, Jairaj PS, Periyanayagam WJ, John S. Achalasia cardia : A review of 100 cases. Aust NZ J Surg 1978; 48: 167-70. Rabushka LS, Fishman EK, Kuhlman JE. CT evaluation of achalasia. J Comput Assist Tomogr 1991; 15 : 434-39. Mohan A et al. Achalasia cardia : Uncommon presentation. Indian J Chest Dis Allied Sci 2001; 43 : 103-105.