The first case involved a 36-year-old male with an extensive medical history of epilepsy, intravenous drug abuse, mitral valve and aortic valve replacement, prosthetic valve endocarditis (with septic emboli), chronic HCV treatment naive, empyema (post video-assisted thoracoscopic surgery), achalasia, and a wheelchair-bound status. At presentation in our institution's emergency department, he complained of dizziness of duration 3 days and denied any other complaint. Vitals signs on presentation were; temperature 37.1℃, blood pressure of 90/60, heart rate 100 beats per minute, and oxygen saturation 92% on room air. Physical examination revealed a cachectic, wheelchair-bound young man. Notable findings included a decubitus sacral ulcer and a jejunostomy tube in place. According to the patient's wife, the jejunostomy tube was placed at another institution in preparation for unspecified surgery, but the patient was non-compliant and continued oral feeds. When obtained, records revealed the patient had been scheduled for Heller myotomy, but the procedure was not performed due to patient non-compliance. Laboratory work-up on admission revealed hemoglobin 10 g/dL, white blood cell count 15×10⁹ per liter, and a platelet count of 213×10⁹ per liter. His hepatic function panel was normal. Due to a history of prosthetic valves, infective endocarditis 6 months previously, and a Quick sequential organ failure assessment score for sepsis of 2, he was empirically started on antibiotics for possible sepsis secondary to prosthetic valve endocarditis. Three hours after admission, the patient had an episode of coffee ground emesis. Repeat labs showed his hemoglobin had fallen to 6 g/dL. Based on this finding, he was transfused with one unit of packed red blood cells and scheduled for emergent upper endoscopy. No esophageal varices or gastric or duodenal ulcers were observed by upper endoscopy, but it did reveal a severely dilated esophagus containing fermenting food (Fig. 1), which was diluted and removed by suction during endoscopy. After clearing the retained food from the esophagus and stomach, Los Angeles (LA) class C esophagitis was noted in the middle and lower thirds of the esophagus, which was considered the likely cause of the coffee ground emesis. CT of the chest and abdomen subsequently showed a dilated esophagus resulting in compression of the right mainstem bronchus and bronchus intermedius (Fig. 2).

During his stay, the patient was uncooperative and refused further treatment or intervention and signed out against medical advice. He was readmitted one month later but subsequently expired from complications of septic shock.

The second case was of a 58-year-old female with a medical history of hypertension, asthma, achalasia, tobacco use, and heroin (methadone) abuse who was referred to our outpatient gastroenterology clinic from SBH Health System. She presented complaining of dysphagia to solid foods and odynophagia in her middle chest of duration one year. Physical examination revealed a thin woman (BMI 19.4 kg/m²) with unremarkable findings. On interrogation, the patient reported she had undergone Heller myotomy 9 years previously and an associated 80-pound weight loss over 8 months. Chest CT, revealed a severely dilated esophagus measuring up to 7.4×7.8 cm in maximal axial diameter and occlusion of the right middle lobe bronchus secondary to the mass effect of the dilated esophagus (Fig. 3, 4). Notably, the patient had been examined at another institution 2 years previously but had been lost to follow up. At that time, chest CT showed a large hiatal hernia with inspissated enteric contents and gastroesophageal junction stricturing. Upper endoscopy was also attempted but aborted due to retained food in the esophagus. The patients' symptoms and radiographic findings were consistent with stricturing at the site of prior myotomy with worsening esophageal dilation manifested as compression of the right middle lobe bronchus. The patient was referred to her primary institution for possible repeat surgical intervention.