Case 32 Answer

Did I stump you? I’ve drawn some arrows around the mass in question. Does it take a course that looks familiar?

Yes, this is the esophagus and yes it is dilated (particularly just above the GE junction but note the anterior bowing of the trachea as well). Should I mention the absence of a stomach bubble? So yes, the answer is: Achalasia

reference: http://radiopaedia.org/articles/achalasia or http://www.learningradiology.com/archives04/COW%20100-Achalasia/achalasiacorrect.htm if you like that better

Could it be something else, adenopathy, posterior mediastinal tumor? Yes, but it is so smooth and followed the course of the esophagus. I would probably just correlate with their history (chest pain anyone?) and if needed, just go straight to the esophagram.