Dysphagia for solids!!!!!!!!!!!

[unseennude]

A 37-year-old male army veteran presents with a 9-month history of food sticking in his throat. He states that he has had pain behind his sternum when he swallows and has halitosis. The patient has more difficulty swallowing solid food than liquids and lost 30 lb in the past year. He has no history of fevers or chills, and he denies any trauma or nausea or vomiting. He is currently taking a proton-pump inhibitor for severe gastroesophageal reflux disease (GERD) that another physician prescribed to him several months ago when his symptoms first began; this medication offers some symptomatic relief. He reports having at least 1 episode of pneumonia in the past.

On physical examination, the patient appears thin but not emaciated. He has normal vital signs, including a normal temperature. Conjunctival pallor is observed. Findings from the cardiac and respiratory portions of the examination are unremarkable. He has a soft, nondistended abdomen with normal bowel sounds. The remainder of the examination yields unremarkable results.



A single-contrast, barium upper-gastrointestinal series (see Images 1-2) and contrast-enhanced chest CT (see Image 3) are performed. What is the diagnosis?


Hint: This is an uncommon cause of dysphagia.

[Oak]

I think its Adenocarcinoma of Oesophagus

[kriss]

it should be the case of achalasia cardia...........

[de.malady]

since Dysphagia is only to solids, it indicates mechanical obstruction to the esophagus. Dx possibly is -Esophageal cancer-.

[unseennude]

Yeh dude Kriss! you are absolutely correct.
The clinical presentation and the X-ray shows the features of Achalasia Cardia.

Achalasia cardia: a disorder of esophageal motility characterized by decreased or absent peristalsis of the esophageal body, increased pressure in the esophagus, and impaired relaxation of the lower esophageal sphincter (LES). The result is impaired esophageal emptying with a resistance to antegrade flow that causes the esophagus to dilate and elongate.

The condition can be is due to loss of ganglion cells in the myenteric plexus of Auerbach or due to malignancy, diabetes, or Chagas disease (Trypanosoma cruzi infection acquired by the bite of an infected reduviid bug). Patients with this condition have an increased incidence of malignancy; approximately 5% developing squamous cell carcinoma, usually in the mid-esophagus.

Dysphagia is the cardinal symptom, present in more than 90% of patients with achalasia. Regurgitation, weight loss, and chest pain or discomfort are other symptoms. Recurrent aspiration of secretions and food material leads to pneumonia.

Chest radiography, often demonstrates a homogeneous, usually right-sided, paramediastinal soft-tissue opacity. Other findings may include mediastinal widening, air-fluid levels, absence of a gastric air bubble (due to a water-seal effect), and complications such as aspiration pneumonia or lung abscess. (Patients with achalasia may have chronic aspiration pneumonia involving Mycobacterium fortuitum-chelonei.)



Fluoroscopic barium swallow demonstrates failure of the contrast agent to enter the stomach, nonpropulsive tertiary esophageal contractions, various degrees of dilatation, and the bird-beak sign (ie, abrupt, smooth tapering of the distal esophagus) (See image 1 and 2).

CT findings are nonspecific and insensitive, with esophageal dilatation usually present (See image 3).

For more information on achalasia cardia, please see Achalasia (within the Emergency medicine or surgery speciality).

[de.malady]

-thankyou- unseennude for the explanations..
i am workin on the correction now..

[Oak]

I miss this, I thought pt. was emaciated

[azureskye33]

unseendude, subscribes to radiocase as well? hehe i subscribe it too..

good work