Achalasia with Recurrent Pneumonias

Discussion:

Because an air/fluid level in the chest could be due to entities as diverse as abscess and trauma -- clinical history is important.
Chest radiography suggests the abnormality to involve much of the thorax.
- A patient with an abscess this size would be much more ill than the patient in this example.
Although CT scan might be considered as the next examination, the size of the abnormality and the history of dysphagia, suggest an UGI exam as a reasonable approach.
The UGI
- Reveals the esophagus to be markedly dilated.
- On the PA view of the chest, the esophagus forms the medial border of the right lung.
- An air/fluid is seen in the superior mediastinum on both the PA an L LAT views similar to what was seen on plain film examination.
- Retained secretions and food are seen in the distal esophagus.
- Delayed esophageal emptying is present.
- The esophagus ends in a characteristic "bird's beak" pattern.
- Coarse infiltrates are seen at the lung bases.

Radiographic findings are compatible with achalasia complicated by recurrent pneumonias.

You may wish to review some facts regarding Achalasia:

Results from failure of the lower esophageal sphincter to relax.
- Probably a defect of cholinergic innervation -- absence or destruction (e.g., Chagas' disease) of myenteric (Auerbach's) plexus.
Classically occurs between ages 20 and 40.
Characterized by dysphagia, worsened by stress, rapid eating.
Regurgitation and aspiration leading to pneumonia is a well recognized complication.
Plain film findings characteristic.
On UGI, weak, non-propulsive peristaltic waves seen with retention of contrast in distal esophagus.
- Esophagus narrows sharply and smoothly to "bird's beak."
Rx:
- Balloon dilation.
- Surgery (Heller long tract myotomy).
Complications of Rx:
- Acute -- esophageal rupture.
- Chronic -- reflux esophagitis and stricture.
DDX:
- Malignant distal lesions (e.g., squamous cell CA)
- Benign lesions (e.g., strictures secondary to esophagitis).

Comment: Because this case has both Chest and GI components, it is stored in both areas.

Ref: Eisenberg, Ronald L., Gastrointestinal Radiology, 2nd ed., Lippincott, Philadelphia, PA., 1990, pp. 11-19.