"Cor bovinum": An ambiguous chest radiography

1. Main sectionA 65-year-old woman, affected by Type II diabetes mellitus with nohistoryofcardiacillness,referredtoourhospitalwithasuspected diag-nosis of “angina pectoris” for a cardiovascular evaluation. The patient'sphysical examination was unremarkable and cardiac laboratory tests,electrocardiogramandtransthoracicechocardiogramwerealsonormal.A standard chest X-ray revealed an ambiguous cor bovinum-like medi-astinal image constituted of dilated thoracic esophagus profile (Fig. 1).At upper gastrointestinal endoscopy any malignancies were ruled outand in-esophagus food stagnation with difficult crossing through theesophagogastricjunctionwasassessed.Adiagnosisofesophagealacha-lasia wassuggested and then confirmed by high resolution manometryas the type 2 esophageal achalasia according to Chicago classification[1]. The patient underwent a laparoscopic Heller's myotomy withDor fundoplication, and at follow-up 12 months later she remainedcompletely asymptomatic.2. Discussion sectionThe achalasia usually presents with progressive dysphagia for bothliquid and solid foods, chest pain, nonacid regurgitation and gradualweight loss. Moreover, esophageal achalasia is currently considered tobe the less prevalent esophageal cause of non cardiac chest pain.Although achalasia can be suspected using clinical, radiographic, andendoscopic information, the esophageal manometry is still the goldstandard diagnostic tool [2], showing absent or abnormal swallowingrelaxation of the lower esophageal sphincter and the absence of peri-stalsis in the esophageal body. Furthermore, the recent clinical