Correct!
5. Primary achalasia
The thoracic CT shows diffuse esophageal distension extending to the level of the gastroesophageal junction, but there is no evidence of mass at the point of esophageal tapering, as would be expected if an esophageal malignancy were causing esophageal obstruction, particularly if carcinoma were the cause of such obstruction. Note, however, esophageal malignancy presenting primarily as stricture may cause obstruction with little evidence of actual esophageal mass at thoracic CT. Barrett’s esophagus typically shows no discernable findings at thoracic CT. A gastrointestinal stromal tumor affecting the esophagus may appears as a solid mass of variable size, which may be eccentric and unassociated with obstruction, or may cause esophageal luminal narrowing resulting in obstruction. Intramural esophageal pseudodiverticulosis appears as numerous, multifocal, “flask-shaped” small intramural esophageal wall oral contrast collections at barium esophagram; these findings would be difficult to detect at thoracic CT. The appearance of extensive upper and mid-esophageal distension extending to a normal-appearing gastro-esophageal junction, without a visible mass, is typical of achalasia, and, while not this consideration cannot be specifically established as a definitive diagnosis at thoracic CT, achalasia is the leading consideration for the CT appearance in this patient.
The patient subsequently underwent barium esophagram (Figure 5) for evaluation of the presumed esophageal dilation seen at chest radiography and thoracic CT.
Figure 5. Upper gastrointestinal barium examination in the AP (A) and oblique (B) projection.
Which of the following represents the most accurate assessment of the barium esophagram findings? (click on the correct answer to be directed to the eighth of eleven pages)