A weird OGD

Now this looks weird. It's a video of a gastroscopy, starting just after intubation ... 
WHAT IS THE DIAGNOSIS?

■ Achalasia

To be specific achalasia type I !

■ Large hiatus hernia

Almost difficult to tell which is oesophagus and what is stomach!

■ Reflux oesophagitis

There is reflux but no oesophagitis

■ Barrett's oesophagus

Oesophagus looks odd but is lined with squamous mucosa

■ Squamous dysplasia

The squamous mucosa is hyperkeratotic but not dysplastic

explanation

This is a patient with end-stage achalasia and a huge, 'sigmoid' oesophagus. OK, the GOJ doesn't look tight but naturally this is because the patient has in the past undergone a myotomy and fundoplication. Patients with 'Type I achalasia' presents with more severe oesophageal dilatation and less spasm-induced pain than in type II and type III achalasia. 

The silly question for the endoscopist was; 'is there anything we can do to improve swallowing'?  Of course, a more important question for the endoscopist was: 'is there any sign of cancer in the distal oesophagus?'  
After all, both SCC and adenocarcinoma may develop with a frequency of about 1:700 patient/years. Which is about half as common as cancer developing in Barrett's.  The GOJ looks a little plump and odd but biopsies did not reveal any neoplasia. Presumably the appearance was due to the previous fundoplication. 

By the way, the classification of achalasia makes no sense to me at all. This is a case of what would be called 'Type I' achalasia, which I suspect is the end stage of Type II achalasia (logically it should then be called 'Type III achalasia' shouldn't it?). The reason for the suggestion is that in 'Type II achalasia', there is still some preservation of the longitudinal muscle contraction and sufficient excitation of the circular muscle to generate intraluminal pressure but with weak forward propulsion. In type III achalasia, there is a 'nutcracker oesophagus' with a spastic gastro-oesophageal sphincter.  

Then again, perhaps the three subtypes of achalasia are three completely separate conditions? 

If you want a reminder of achalasia, here is a link to a good article!