Dysphagia and oesophageal dilation in giant hiatus hernia: angulation of the gastro-oesophageal junction or achalasia?

The co-existence of achalasia and large para oesophageal hernia (PEH) is uncommon. The anatomical disruption of the GOJ mechanism by hiatal herniation may result in chronic angulation and secondary partial oesophageal obstruction. A unique case is described where the diagnostic uncertainty of coexistant achalasia and PEH with angulation causing chronic oesophageal obstruction existed. This case highlights the importance of multimodality workup of oesophageal disorders utilising endoscopy, fluoroscopy and manometry. Accurate identification of physiological abnormalities allowed appropriate design of operative intervention.