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Radiological signs in achalasia.

CLINICAL PRESENTATION A 43-year-old man presented with dysphagia to both liquids and solids which was getting progressively worse over the past 2 weeks with difficulty even swallowing his saliva. He also noted regurgitation of food eaten over the past 2 days and had mild chest pain. He did not complain of any history of severe acid reflux and denied any weight loss. He had a history of similar complaints 20 years ago when, as per him, he was advised to undergo balloon dilatation. However, the symptoms had resolved without any treatment, and he had not followed up with any physician since then until this visit. He had no other medical problems and was not taking any medications. On physical examination, his vitals were stable, he did not seem to be in any acute distress and there were no positive findings on examination. A chest x-ray (Figure 1) demonstrated massively distended thoracic esophagus, and a barium swallow study (Figure 2) showed massively dilated esophagus with marked narrowing of gastroesophageal junction in a bird’s beak appearance. Therefore, in keeping with the clinical presentation and the radiographic information, a diagnosis of achalasia was made. The patient was kept nil per oral and started on intravenous fluids. A balloon dilatation was attempted; however, the endoscope could not be advanced to the gastroesophageal junction despite several attempts because of the retained solid food particles. A computerized tomographic scan of the chest and abdomen was then performed which did not reveal any esophageal mass but did show massive dilatation of the patient’s esophagus with retained fluid and oral contrast consistent with achalasia. A decision was then made to proceed with surgical intervention, and he was treated with laparoscopic Heller’s myotomy. He had relief of symptoms and was able to tolerate oral intake at the time of discharge. REFERENCES