An extreme megaesophagus causing lung collapse

An 83-year-old male with long-term dysphagia and weight loss was admitted due to an acute ST-elevation myocardial infarction. During hospitalization he developed hematemesis requiring several red blood cell transfusions. An upper endoscopy was attempted being interrupted due to esophageal high-volume stasis. Despite remaining fasting for several days and naso-esophageal tube drainage, three additional upper endoscopies still revealed non-removable solid food stasis in a markedly dilated esophagus and bleeding from severe underlying esophagitis. A thoracic CT confirmed an aberrant and massive esophageal dilation with 110x100mm and large food impaction leading to almost complete right lung atelectasis and respiratory failure. A narrow esophagogastric junction and no apparent associated obstructive lesions were also observed on CT scan. Based on clinical symptoms and radiologic findings a presumptive diagnosis of achalasia was considered although it could not be confirmed through esophageal manometry. Parenteral nutrition was started. Nevertheless, the patient died a few days later from aspiration pneumonia.