A typical megaesophagus: interesting imaging for diagnosis.

To the Editor: The dramatic expansion of an esophagus is extremely rare in esophageal diseases. We present a case of megaesophagus associated with atelectasis of the right lung, which showed a typical of achalasia with a “bird's beak appearance”. In order to palliate patient's symptoms, two gastric tubes used. One was inserted into the esophagus for suction residual chymus, the other was inserted into the stomach for supplying nutrition. However, after the symptoms eased, she refused all further treatment.

A 53-year-old woman was hospitalized because of dysphagia for 13 years with squeezing chest pain and retrosternal obstruction. This symptom could be alleviated after vomiting. She suffered from fever (highest 40°C) with chilly and shivering after eating for a week. Physical examination disclosed that breath sound in the right lung was lower than the left lung, cardiac rhythm and heart sound were normal. Upper gastroenterography showed that a large area of patchy shadows on the right chest, upper esophagus was expanded, with an unsmooth inner wall. No barium was in the stomach [Figure 1a]. The gastroscope examination showed that the inner diameter of upper segment of esophagus was expanded obviously, and the entrance of cardia (ostiumcardiacum) became narrow which it was hard to pass with gastroscope [Figure 1b and 1c]. Sixteen-slice computed tomography scan revealed the middle lobe of right lung was detected atelectasis in lung window because of compression from enlarged esophagus, and upper esophagus expanded obviously [Figure 1d], lower esophagus and cardia became significantly narrow and mucous membrane around of this area also was thick in soft tissue window. Due to infection caused by corruption of chyme deposited in esophagus, we decided to alleviate symptoms of obstruction (two gastric tubes were used, one was inserted into the esophagus for suction residual chymus, the other was inserted into the stomach for supplying nutrition), and antibiotics was used at the same time as another main treatment. However, after the symptoms eased, she refused all further treatment.

Figure 1

Barium meal X-ray examination showed a dilated esophagus with tapering at the distal end. This tapering is often referred to as “bird's beak appearance” and is typical of achalasia and a large area of patchy shadows on the right chest (a). On upper gastrointestinal endoscopy, the inner diameter was expanded obviously of the upper esophagus (b) and the scope could not be moved beyond the gastroesophageal junction (c). A 16-slice computed tomographic plain scan showing the upper esophagus expanded obviously (d).

It is so serious that can result in lung atelectasis and aspiration pneumonia. These cases have been reported sudden death secondary to megaesophagus.[1] Esophageal achalasia is a comparatively rare disease which usually presents with esophageal motility dysfunction characterized by failure of esophageal peristalsis and lack of relaxation of the lower esophageal sphincter. The incidence of esophageal achalasia is approximately 1/100,000 annually.[2]: Drug treatment is not effective, surgical procedure is most widely used to treat esophageal achalasia, while the conventional surgical injury is severe. Pneumatic dilation, laparoscopic Heller myotomy with fundoplication and per oral endoscopic myotomy has since become more popular due to less invasive and a similar outcome.[3] Two gastric tubes were used in this patient palliated patient's symptoms, improved the quality of life, and got a satisfactory preliminary status. However, after the symptoms eased, she refused a subsequent surgical treatment.