Solid Food Dysphagia

1
Solid Food Dysphagia

• Stephen Antonik, MD
• Konrad Soergel, MD
• Benson Massey, MD
• August 6, 2007

2
HPI

• 66 y/o/m with SLE and A fib
• 4 wks of progressive dysphagia
• solids and rare full liquids
• food gets caught mid-sternum
• Severe heartburn 15 minutes after eating
• Poor appetite, 30 pound wt loss over 3 mos
• Denies globus, odynophagia, choking, coughing,
  pneumonia, chest pain, nausea/vomiting
• Able to belch

3
PMH/PSH

• SLE dx 2001 complicated by pneumonitis and
  pericarditis s/p median sternotomy and total
  pericardiectomy 2003
• Atrial fibrillation/flutter s/p cardioversion
  1/07
• h/o CVA
• h/o Scarlet fever
• s/p cholecystectomy/appendectomy
• Anemia, Colonoscopy tubular adenoma and EGD
  gastritis, H. pylori positive

4
Medications

• Prevacid daily
• Tums PRN
• Azathioprine 50 mg daily
• Prednisone 5 mg daily
• Coumadin
• Toprol
• Flecainide
• Neurontin

5
Physical Exam/Labs

• VSS
• GEN NAD, comfortable
• CV RRR
• CHEST non-tender
• ABD NABS, soft, non-distended, non-tender, no
  masses
• Alb 2.5, Hgb 12 (baseline), INR 4.5

6
Radiology CXR

• Normal PA/LAT

7
Radiology Esophagram

• Age related esophageal dysmotility with a poor
  primary wave and intraesophageal reflux.
• Narrowed mid to distal esophagus likely
  representing chronic esophagitis or stricture.

8
Endoscopy

• Mid-Distal Esophagus
• Retained barium 1 day after esophagram.
• No strictures or webs noted
• Esophagus distended well, however spasmotic
  contractions were noted in the distal esophagus.
• Random biopsies were taken which were
  unremarkable.

9
Manometry

• Water swallow
• immediate initial pressure wave which is isobaric
  and transmitted throughout the entire esophagus
  as a water hammer pressure pulse
• This indicates a stiff wall with suggestion of a
  partially filled esophagus
• Note the high pressure zone 50-70 mmHg in
  midesophagus
• Dry swallow
• peristaltic wave with high ramp pressure above
  the high pressures zone suggesting resistance

10
CT

• A large mass involving the mid and distal
  thoracic esophagus, encasing the distal
  descending thoracic aorta, and extending into
  both the paravertebral regions and also probably
  into the pleura. Bilateral pleural effusions.
• Superior segment of the left lower lobe shows an
  area of consolidation and ground-glass opacities
  with areas of interlobular septal thickening,
  suggestive of lymphangitic spread.
• Enlarged axillary nodes, posterior mediastinal
  nodes, retrocrural nodes, and celiac nodes.

11
Patient Course

• Patient was taken to the OR for an excisional
  right axillary node biopsy

12
Pathology

• Right axillary lymph node excisional biopsy
• Sheet like growth that obliterates the normal
  lymph node architecture. The spaces are adjacent
  entrapped fat cells.
• Large neoplastic cells with prominent nucleoli.

13
Final Diagnosis

• After PET and CT Abdomen and Pelvis
• Diffuse Large Cell Lymphoma with bone marrow,
  mediastinal and lymph node involvement

14
Discussion

• Esophageal manifestations of SLE
• Dysphagia (1 to 13 of patients)
• GERD (11 to 50 of patients)

15
Discussion

• Causes of Dysphagia in SLE
• GERD or peptic stricture
• Motility Disorder (hypotonic LES or low amplitude
  peristalsis)
• Castrucci et al 1974 Hypoperistalsis or
  aperistalsis in 13/18 (72)
• Rameriez-Mata et al 1982 Motility abnormalities
  in 16/50 (32)
• Gutierrez et al 1990 8/14 Esophageal symptoms,
  3/14 (21) with hypoperistalsis, Good correlation
  with Raynauds and aperistalsis
• Lapadula et al 1994 12/19 (63) abnormal
  manometry
• Report of esophageal epidermolysis bullosa
  acquisita
• Candidaiasis on steroids and/or immunosuppression
  
• NSAIDs related ulceration

16
Discussion

• SLE and increased risk of NHL
• Due to immunologic derangements, genetic factors,
  viruses, or medications
• Diffuse large B cell lymphoma most common subtype
• Most EBV negative

17
Summary

• Evaluation of solid food dysphagia in this
  patient utilized many modalities. Initially, the
  esophagram suggested a distal esophageal
  structural abnormality. The EGD revealed normal
  mucosa. However, the spasms of the distal
  esophagus suggested a motility disorder versus
  stiff esophagus (intrinsic or extrinsic).
  Manometry provided further information of the
  location of the pathology, notably, a high
  pressure zone in the mid-esophagus. During wet
  swallows there was an immediate isobaric high
  pressure wave throughout the entire esophagus.
  This suggested a stiff esophagus. Interestingly,
  during a dry swallow there was peristalsis above
  the high pressure zone with an increasing ramp
  pressure. After the high pressure zone there is
  essentially no motility. This study narrowed the
  differential to compression in the thoracic
  esophagus, ie dysphagia aortica, tumor, etc. CT
  and biopsy provided the final diagnosis.

18
References

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