Q J Med 2014; 107:583

doi:10.1093/qjmed/hct234 Advance Access Publication 19 November 2013

Clinical picture

Achalasia and the rat’s tail sign

Case report a small proportion occurs secondary to other condi-

A 15-year-old young male presented with a progres-
sive of dysphagia for solid and liquid food over a
period of 6 months. He denied any drug, foreign
body or corrosive ingestion. Physical examination
showed non-remarkable findings. Chest radiograph
revealed a convex radiopacity overlapped the right
heart border (Figure 1a). Computed tomography
(CT) indicated a dilated esophagus, free of external
compression. Barium esophagogram revealed a
smooth narrowing of the distal esophagus with the
characteristic ‘rat’s tail’ appearance (Figure 1b).
tions, such as esophageal cancer or Chagas’ disease.1
In addition, external compression such as pancreatic
pseudocyst has been reported mimicking achalasia.2
It is this potential pitfall that mandates endoscopy and
CT as part of the diagnostic evaluation.
Photographs and text from: Wen-Chien Cheng,
Te-Chun Shen and Chih-Yen Tu, Department of
Internal Medicine, China Medical University
Hospital and China Medical University, Taichung,
Taiwan and Department of Internal Medicine, Chu
Shang Show Chwan Hospital, Nantou, Taiwan.
email: chestshen@gmail.com

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Achalasia was confirmed by esophageal manome-
try. The patient underwent laparoscopic Heller
Conflict of interest: None declared.
myotomy, which improved his symptoms.
Idiopathic achalasia is a syndrome caused by in-
complete relaxation of the lower esophageal sphinc-
ter. The physiologic alterations result from damaged References
innervation. On the barium swallow study, a dilated 1. Spiess AE, Kahrilas PJ. Treating achalasia: from whalebone to
esophagus tapering at the distal end, which is referred laparoscope. JAMA 1998; 280:638–42.
to as ‘rat’s tail’ or ‘bird’s beak’ appearance. The ‘rat’s 2. Gupta N, Raghuram K, Puri AS. Recent-onset dysphagia in a
tail’ sign is typical of idiopathic achalasia; however, young man. Gastroenterology 2013; 144:e1–e2.

Figure 1. (a) Chest radiograph shows a right-sided convex shadow beyond the heart border (arrows). (b) Barium esophago-
gram reveals a typical ‘rat’s tail’ sign at the lower esophageal sphincter.

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