Lehigh Valley Health Network Easton, PA, United States
Margaret Spinosa, MD1, Henry Lam, DO1, Matthew J. Sullivan, DO2 1Lehigh Valley Health Network, Allentown, PA; 2Eastern Pennsylvania Gastroenterology and Liver Specialists, Allentown, PA
Introduction: Chronic dysphagia is a common complaint with wide differential diagnoses that can include neurologic, functional and mechanical etiologies. Mechanical etiologies of esophageal dysphagia can include peptic strictures, lower esophageal rings, and malignancy. Sometimes these can be difficult to differentiate from primary esophageal motility disorders and examining all available information including patient history, imaging and endoscopic findings can lead to a diagnosis.
Case Description/Methods: A 73 year old woman with metastatic ER/PR positive HER 2 negative breast cancer and chronic dysphagia with multiple hospital admissions for acute exacerbation of her symptoms. She had imaging studies which in the past had showed distal esophageal wall thickening. She had a barium swallow which was suggestive of esophageal dysmotility with tapered narrowing and poor distensibility of the esophagus and on initial EGD only erosive gastritis and bulbar duodenitis was seen. This was followed with high resolution esophageal manometry which showed an elevated IRP with preserved peristalsis most consistent with esophagogastric junction outflow obstruction. With persistent symptoms, she underwent a repeat EGD followed by endoscopic ultrasound which showed a long smooth stricture approximately six centimeters in length which could now only be traversed with an ultra-slim video gastroscope. The stricture had a benign appearance on endoscopic examination and the patient underwent serial dilation with Savary dilator. Biopsies were taken for pathology review and resulted as metastatic carcinoma in her stricture.
Discussion: In the evaluation of esophageal motility disorders, diagnoses are often made with combination of information from imaging, endoscopic and manometric studies. The differential should be kept wide and re-visited during evaluation. Subtle pathology can be missed on endoscopy alone and this patient with esophagogastric outflow obstruction diagnosed by esophageal motility study ultimately was found to have malignant infiltration of the distal esophagus though initial endoscopic evaluation did not reveal a mechanical obstruction and even on repeat endoscopy patient had a benign appearing esophageal stricture. Ultimate diagnosis was made by biopsy due to high index of suspicion given clinical history.
Disclosures: Margaret Spinosa indicated no relevant financial relationships. Henry Lam indicated no relevant financial relationships. Matthew Sullivan indicated no relevant financial relationships.
Margaret Spinosa, MD1, Henry Lam, DO1, Matthew J. Sullivan, DO2. P2456 - Cancer Is the Answer: Making the Diagnosis in a Patient With Esophagogastric Junction Outflow Obstruction, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
