European Journal of Radiology Extra 50 (2004) 89–92 Secondary achalasia caused by peripheral cholangiocarcinoma in left lobe of the liver Sang-Wook Yoon b , Jeong-Sik Yu a,* , Hyo-Jin Park c , Mi-Suk Park a , Hee Jin Kim b , Ki Whang Kim a a Department of Diagnostic Radiology and Research Institute of Radiological Science, Yonsei University College of Medicine, Yongdong Severance Hospital, 146-92 Dogok-Dong, Gangnam-Gu, Seoul 135-270, South Korea b Department of Diagnostic Radiology, College of Medicine, Pochon CHA University, Bundang CHA Hospital, 351 Yatap-Dong, Bundang-Gu, Sungnam-Si, Gyunggi-Do 463-712, South Korea c Department of Internal Medicine, Yonsei University College of Medicine, Yongdong Severance Hospital, 146-92 Dogok-Dong, Gangnam-Gu, Seoul 135-270, South Korea Received 17 November 2003; received in revised form 16 February 2004; accepted 18 February 2004 Abstract Secondary achalasia caused by malignancy is an infrequent disorder. A 61-year-old woman presented with dysphagia and 8 kg weight loss during 8 months. Barium esophagography showed an esophageal dilatation with smooth tapering at the distal esophagus near the lower esophageal sphincter (LES). Endoscopic ultrasonography demonstrated loss of normal layering and wall thickening at LES area. CT revealed a 5 cm sized low density mass adjacent to the esophagogastric junction in left lobe of the liver, which was confirmed as cholangiocarcinoma. It is the first report of the secondary achalasia caused by peripheral cholangiocarcinoma in left lobe of the liver. This case highlights the fact that endoscopic ultrasonography and cross-sectional imaging such as CT must be required in the case of recent onset of dysphagia in older patient to rule out secondary achalasia. © 2004 Published by Elsevier Ireland Ltd. Keywords: Esophagus; Achalasia; Cholangiocarcinoma; Endoscopic ultrasonography; Computed tomography 1. Introduction Achalasia is an uncommon but not rare motility disorder of the esophagus. One of the alarming mimickers of idio- pathic achalasia is secondary achalasia caused by various malignancies. In the majority of cases, gastric adenocarci- noma is an underlying cause of secondary achalasia. But, lung cancer, lymphoma, malignant mesothelioma, hepato- cellular carcinoma, squamous esophageal carcinoma, pan- creatic carcinoma, and prostate cancer were also reported as causes of this condition [1–4]. This is the first report of sec- ondary achalasia caused by peripheral cholangiocarcinoma and that the clinical and radiological findings are discussed as well as the diagnostic work up of the case. * Corresponding author. Tel.: +82-2-3497-3516; fax: +82-2-3462-5472. E-mail address: yjsrad97@yumc.yonsei.ac.kr (J.-S. Yu). 2. Case report A 61-year-old woman was admitted to our hospital, com- plaining of dysphagia and odynophagia. She had developed symptoms to semisolid diets and experienced an 8 kg weight loss during the previous 8 months. Her past medical history was unremarkable and the laboratory and physical examina- tion findings were within normal limit. Barium esophagography showed an esophageal dilatation with smooth tapering at the distal esophagus near the lower esophageal sphincter (LES) (Fig. 1A). The mucosa of the esophagus and stomach were normally demarcated. Barium esophagography showed the absence of primary peristalsis and the presence of tertiary contractions. Manometric find- ings indicated the absence of esophageal peristalsis and LES relaxation on swallowing. The initial diagnosis was acha- lasia. During esophagogastroendoscopic examination, the endoscope passed the esophagogastric junction only with some resistance. The retroflexed endoscopic view showed 1571-4675/$ – see front matter © 2004 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejrex.2004.02.004