Pseudoachalasia from gastric cardia tumor

Case contributed by Dr Matt A. Morgan

Presentation

Dysphagia with spasms. 10 lb weight loss. Normal upper endoscopy seven months earlier.

Patient Data

Age: 80 years
Gender: Female

Esophagram

Barium

On the upright LPO images, the esophagus is mildly dilated and tapers to a "bird beak" at the level of the lower esophageal sphincter.

On the prone RAO images, the normal cardiac rosette cannot be seen and instead there is a 3.0 x 4.7 cm gastric cardia mass causing obstruction to esophageal outflow into the stomach.

Annotated image

On these annotated images, the yellow arrow points to the "bird beak" that is classically associated with achalasia. The red oval shows the large gastric cardia tumor causing the obstruction.

Upper endoscopy

Photo

Follow up upper endoscopy shows a large, mildly friable mass at the gastroesophageal junction and in the cardia

Case Discussion

The "bird beak" appearance is classic for primary achalasia, but secondary achalasia or "pseudoachalasia" should be considered in a patient with a suspicious clinical history ("pseudo-" because the tapering at the lower esophageal sphincter is not from a myenteric plexus abnormality, but instead from obstruction). Primary achalasia is unlikely to have a rapid onset in an elderly patient and one should look carefully to ensure that no mass is causing the findings.

In this particular case, the mass was a poorly differentiated adenocarcinoma at the gastro-esophageal junction.

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