Can't Stomach It: A Dilated Tale of Achalasia

Achalasia is a common esophageal motility disorder defined by impaired relaxation of the gastroesophageal junction (GEJ). Complications can occur secondary to achalasia, such as dysphagia, weight loss, chest pain, aspiration, and esophageal rupture. This report discusses a case of massive esophageal dilatation, also known as megaesophagus, in the setting of achalasia. This case highlights the complications secondary to achalasia, such as aspiration, pneumatic cysts, weight loss, dysphagia, and esophageal dilatation, and describes the multidisciplinary approach needed to manage patients with severe achalasia disease, with gastroenterology, pulmonology, and general surgery interventions required.  An 80-year-old male presented to the emergency department with a two-week history of progressively worsening dysphagia, accompanied by an inability to tolerate oral intake for several days. Initial computed tomography imaging revealed marked esophageal dilation with significant retained food debris, consistent with advanced achalasia. Additional imaging identified a right middle lobe pulmonary abscess, presumed secondary to aspiration. The patient had a known history of achalasia, previously managed with esophageal dilation, though they had not required intervention for several years prior to this hospitalization. The patient reported experiencing intermittent episodes of dysphagia since their last treatment; however, these episodes resolved spontaneously and did not prompt evaluation. In this instance, the prolonged duration and worsening of symptoms led to their presentation to the emergency department. The gastroenterology service was consulted for endoscopic evaluation and therapeutic dilation of the stricture. Due to the extent of the esophageal dilatation, measuring approximately 11 cm in diameter, fluoroscopic guidance was required to traverse the GEJ and enter the stomach. Endoscopy confirmed a significantly dilated esophagus with no food residue in the stomach with grossly normal-appearing gastric mucosa. A balloon dilation was successfully performed across the narrowed esophageal segment. Given the patient's cachectic appearance and evidence of aspiration with pulmonary sequelae, general surgery was consulted for gastrostomy tube placement to minimize aspiration risk and provide nutritional support.  Achalasia is a primary esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and absent peristalsis of the esophageal body, leading to progressive obstruction and esophageal stasis. Over time, chronic retention of food and secretions can result in marked dilatation of the esophagus, sometimes referred to as megaesophagus when the diameter exceeds 6 cm. While esophageal dilation is a well-recognized complication, extreme dilation, exceeding 10 cm, is rare and may reflect long-standing disease. Prompt diagnosis and referral for cases of achalasia are critical; delays in treatment can lead to severe complications, including aspiration and malnutrition. Management may involve a multidisciplinary approach with gastroenterology and possible general surgery for pneumatic dilation, botulinum toxin injection, and myotomy evaluation, respectively. Timely recognition and coordination between inpatient and outpatient care teams is imperative for optimizing outcomes.