Achalasia with megaesophagus

A 29-year-old man was presented to the emergency department with worsening heartburn and regurgitation, despite taking proton pump inhibitors and antacids for several months. He had a 10-year history of dyspepsia with dysphagia of solid and liquid food. They obtained a chest radiograph, which showed lateralization of the azygoesophageal recess with a right posterior mediastinal mass density. A computed tomography (CT) scan showed a markedly dilated esophagus with a thick, calcified wall. An upright barium esophagram showed a dilated proximal esophagus with distal narrowing in a bird's beak morphology (arrow). Suspecting achalasia or esophageal cancer causing pseudoachalasia, they arranged for the patient to undergo upper endoscopy, which showed no evidence of tumor and was consistent with achalasia. He underwent a peroral endoscopic myotomy (POEM). At 2-year follow-up, he was doing well, with good oral intake and an Eckhardt score (a clinical score for achalasia that had improved from 12 to 1.