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Achalasia has an insidious onset, and disease progression is gradual. Patients typically experience symptoms for years prior to seeking medical attention, with a mean duration of symptoms of 4.7 years [1]. The delay in diagnosis is mainly due to misinterpretation of typical clinical features rather than atypical findings, and many patients are treated for other disorders, such as reflux, before diagnosis [2]. We report the case of a 56-year-old man who was referred after a 36-year history of progressive dysphagia with occasional complaints of chest pain and regurgitation without significant weight loss (Eckardt score 5, weight 72kg, body mass index 20.8kg/m2). A computed tomography scan showed a 13-cm dilated esophagus with residual food (●" Fig.1). Although manometry was difficult because of the sigmoid shape, the result was consistent with achalasia. Fig.1 Computed tomography scan showing the esophageal dilation. a The 13cm dilation (arrow) containing a large amount of residual food. b The same aspect in the middle third of the esophagus (arrow). c Dilation in the lower third of the esophagus.

endoscopy

Use of a long, stiff, overtube placed by a colonoscope to facilitate the POEM procedure for a 36-year history of achalasia with 13-cm esophageal dilation