Achalasia: Pinstripe pattern

A 38-year-old man with no medical history presented to the author’s department with a 1-year history of progressive dysphasia. Oesophagogastroduodenoscopy showed abnormal retention of fluid in the oesophagus. In addition, narrow band imaging (NBI) revealed longitudinal superficial wrinkles forming a ‘pinstripe pattern’ in the lower oesophagus (Fig. 1). These findings suggested achalasia. Oesophageal manometry confirmed the diagnosis of achalasia, and the patient underwent peroral endoscopic myotomy (POEM).

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FIG 1.

Narrow band imaging showing longitudinal superficial wrinkles, also known as ‘pinstripe pattern’

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Although achalasia is a well-known risk factor for oesophageal cancer, there is no known way of preventing or reversing achalasia.¹ The recent development of less invasive and curative treatments such as POEM emphasizes the importance of early diagnosis for achalasia.²

In general, achalasia is diagnosed by oesophageal manometry.^1,2 However, in Japan, this examination has not gained widespread use.² In Japan, a new endoscopic appearance ‘pinstripe pattern’ is believed to be a reliable indicator for early detection of achalasia: the sensitivity and specificity have been reported to be 64.7% and 100%, respectively.² The pathogenesis may be associated with early changes in the superficial epithelium before mucosal thickening due to chronic retention of food.² Since the ‘pinstripe pattern’ can be missed at standard white light endoscopy, NBI as well as indigo carmine dye spray is used for detection.²

In many countries, endoscopy has a relatively minor role other than to exclude pseudoachalasia.¹ The ‘pinstripe pattern’ is still not used in routine practice; therefore, this finding is worth revisiting.