PROBLEM
A 60-year-old woman presents to your emergency department complaining of regurgitation and dysphagia. What diagnosis can you make based on this chest film?

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ANSWER
The patient has esophageal achalasia. Note the broadening of the superior mediastinum to the right and the air-fluid level in the lower neck. This appearance is typical for obstruction of the distal esophagus due to achalasia. Care should be taken to differentiate achalasia from esophageal carcinoma, which has a similar appearance.

This series of diagnostic quizzes that challenge your ability to read a variety of x-ray films is edited by Dr. Keats, alumni professor of radiology at the University of Virginia School of Medicine in Charlottesville. Emerg Med 40(3):55-6, 2008