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The NewYork-Presbyterian Emergency Department radiology teaching files database has been built up over the last several years. All cases in the database were seen at the NewYork-Presbyterian Emergency Department. This case is drawn from the database. Review the image and read the corresponding case before going on to the answers.

An 81 year old female with ongoing weight loss presented to clinic complaining of persistent weight loss and several days postprandial vomiting. She had been avoiding solids altogether, and when she drank liquids, she would experience severe epigastric pain followed by vomiting. At clinic she also complained of weakness and lightheadedness when standing. She was referred to the ED for further evaluation.

Q: What’s wrong with this picture?

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A:

The esophagus is very dilated and contains an air fluid level. (Look just behind the trachea and just above the arch of the aorta.)

Q: What is your differential diagnosis?

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A:

Some type of esophageal dysmotility (such as achalasia) versus an anatomic blockage.

Q: What would you do next?

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A: There are several options to further elucidate the cause of the abnormality seen on x-ray. They include barium swallow, endoscopy or esophageal manometry. In this case, the patient underwent an esophagram which suggested the presence of a distal esophageal mass. EGD was then performed which discovered a very tight lower esophageal sphincter (rather than a mass) as well as a large excavated necrotic-appearing cavity with purulent drainage in the antrum of the stomach.