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Megaesophagus is primarily associated with achalasia because, in this condition, there is a failure of the lower esophageal sphincter to relax properly during swallowing. This results in a backup of food and liquid, causing the esophagus to dilate and leading to the characteristic enlargement known as megaesophagus. The disruption in normal peristalsis in the esophagus contributes to this condition, making it a direct result of the underlying mechanism in achalasia.

In contrast, while gastroesophageal reflux disease involves the movement of stomach contents back into the esophagus, it does not typically result in the significant dilation of the esophagus that characterizes megaesophagus. Pyloric stenosis is primarily a gastric condition affecting the outlet of the stomach and usually does not directly impact the esophagus in a way that would cause megaesophagus. Lastly, esophageal stricture may lead to difficulty with swallowing and potential obstruction but does not typically lead to the enlargement of the esophagus as seen in megaesophagus.