Clinical Presentation

A 71-year-old man presents with halitosis.

(A) Frontal chest radiograph shows a large, air-filled structure extending from the upper to the lower chest (arrowhead) and a large air-fluid level in the retrocardiac left lower chest (arrow). (B) Barium study shows a markedly dilated esophagus, or “megaesophagus” (arrows), a “rat tail” deformity of the lower esophageal sphincter (arrowhead), and slow passage of contrast into the stomach. (C) Delayed image shows a large, round paraesophageal collection containing an air-fluid level and dependent layering of barium (arrows).

Differential Diagnosis

• Achalasia with epiphrenic diverticulum: This is the top choice, given the megaesophagus, the rat tail stricture of the distal esophagus, and an epiphrenic saccular outpouching from the esophagus.

• Secondary achalasia and pseudoachalasia: