PMC4200884_01
(A) Chest radiograph showing a dilated oesophagus (red arrows). A nasogastric tube is seen in the lumen of the oesophagus. Oesophageal contents are visible as a fluid level (white arrows) behind the right heart border. (B) Coronal CT scan of thorax showing oesophageal dilatation (red arrows) with tapering towards the gastro-oesophageal junction (bird's beak sign). Food debris is seen at the distal end of the oesophagus. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)
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On that admission, chest radiography and contrast-enhanced computed tomography (CT) of the neck, abdomen and thorax had demonstrated gross oesophageal dilation, as well as acute oesophageal tapering at the gastro-oesophageal junction: bird's beak sign (Fig. 1).
Clouse plots demonstrating typical patterns in achalasia. In a non-pathological oesophagus, the background colour of the plots is blue, denoting low resting pressure. In this patient with achalasia, the green background in (A) denotes a raised minimal resting pressure of 44.8 mmHg and the green-yellow strip denotes an LES pressure of 57 mmHg. (B) Pressures reached 200 mmHg on swallowing 5 mm of water. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)
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The diagnosis of achalasia with tracheal compression (Chicago classification) was subsequently confirmed by manometry: LES pressure of 57 mmHg (hypertensive) and minimal resting pressure of 44.8 mmHg (Fig. 2).
(A) Sagittal and (B) coronal CT views showing the oesophagus (red arrows) completely impacted with food debris. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)
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An updated CT scan revealed further enlargement of the oesophagus and was now completely filled with food debris suggesting a further reduction in oesophagogastric transit (Fig. 3).
Axial CT image showing the trachea (black arrow) compressed to 4.31 mm by an enlarged oesophagus (red arrows). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)
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The oesophagus was noted to be further dilated, causing compression of the upper trachea to less than 5 mm in parts (Fig. 4).
Pathological specimen of resected dilated and thickened oesophagus.
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In the third stage the cervical oesophagus was mobilised via a left sternocleidomastoid incision and an 8 cm x 8 cm oesophagus excised (Fig. 5).