SummaryBackgroundPseudoachalasia is a condition in which clinical and manometric signs of achalasia are mimicked by another abnormality, most often a malignancy.AimTo identify risk factors that suggest presence of malignancy‐associated pseudoachalasia.MethodsIn this retrospective cohort study, achalasia patients newly diagnosed by manometry were included. Patients with a normal initial endoscopy, clinical and manometric signs of achalasia who were afterwards found to have an underlying malignant cause were classified as pseudoachalasia. Clinical and diagnostic findings were compared between malignant pseudoachalasia and achalasia.ResultsWe included 333 achalasia patients [180 male, median age 50 (38–62)]. Malignant pseudoachalasia was diagnosed in 18 patients (5.4%). Patients with malignancy‐associated pseudoachalasia were older at time of diagnosis [67 (54–71) vs. 49 (37–60) years], had a shorter duration of symptoms [6 (5–10) vs. 25 (11–60) months] and lost more weight [12 (9–17) vs. 5 (0–12) kg). In 61% of the pseudoachalasia patients, the oesophagogastric junction (OGJ) was difficult or impossible to pass during endoscopy, compared to 23% in achalasia. Age ≥55 years (OR 5.93), duration of symptoms ≤12 months (OR 14.5), weight loss ≥10 kg (OR 6.73) and difficulty passing the OGJ during endoscopy (OR 6.06) were associated with a higher risk of malignant pseudoachalasia.ConclusionsAdvanced age, short duration of symptoms, considerable weight loss and difficulty in passing the OGJ during endoscopy, are risk factors that suggest potential malignancy‐associated pseudoachalasia. To exclude pseudoachalasia, additional investigations are warranted when two or more risk factors are present.