This 52 year old lady was referred for achalasia balloon dilatation from another hospital where an upper GI endoscopy had also been done and was reported to be unremarkable. Her esophageal manometry suggested achalasia of the cardia. We went in with a plan for balloon dilatation of the lower esphageal sphincter. However, extensive infiltration was seen at the cardia (A) and in antral area (B). Dilatation was, of course, cancelled. We took biopsies and advised a biphasic CT of the chest and abdomen. The important lesson was that even when going for an achalasia dilatation in a fully worked up case, always have a good look at the cardia to rule out pseudoachalasia.
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