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Dysphagia

Dysphagia. Student Name: Jack Li Period: 3 Date: 7/22/09. History. CC: “difficulty swallowing” HPI: 85 yo ♂ c/o dysphagia (solids > liquids) x 6-7mos, wt loss 5 lbs past wk / 20lbs past 1.5 yrs, “spits up” food and saliva, feels food “stuck” in chest, Ø heartburn/N/V

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Dysphagia

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  1. Dysphagia Student Name: Jack Li Period: 3 Date: 7/22/09

  2. History • CC: “difficulty swallowing” • HPI: 85 yo ♂ c/o dysphagia (solids > liquids) x 6-7mos, wt loss 5 lbs past wk / 20lbs past 1.5 yrs, “spits up” food and saliva, feels food “stuck” in chest, Ø heartburn/N/V • PMH: newly dx RCC (07/2009), HTN, HLD, chronic renal insufficiency, BPH • FHx: pancreatic CA (mother), breast CA (sister) • SHx: prior smoker 25+ pack-yrs, social EtOH, Ø IVDU • Meds: omeprazole, simvastatin, lisinopril, atenolol, ASA • Allergies: terazosin

  3. Physical Exam and Labs • Physical exam: • Vitals: T 98.1 P 54 R 20 BP 203/91 • Abdomen: soft, non-tender, non-distended • No other significant findings • Labs: • WBC: 7.0 • Hgb: 13.3 • Plts: 207 • Na 138, K 4.3, Cl 102, bicarb 29, BUN 15, Cr 1.4 Gluc 116 • Ca: 9.1 • protein 6.5, albumin 3.7 • AST/ALT/alk. phos: 18/18/51 • PTT 25.1, INR 1.0

  4. Findings • Barium swallow study: double contrast, biphasic exam • No abnormal swallowing function • Ulcerating mass at esophagogastric junction • Moderate stricture 1 cm in width, 4 cm in length • Delayed passage of contrast • Minimal dilatation of proximal adjacent esophagus • No extravasation of contrast

  5. Images

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  8. Differential Diagnosis • High • Adenocarcinoma • Squamous cell carcinoma • Asymmetric scarring • Barrett’s esophagus • Low • Schatzki’s ring • Reflux esophagitis (scarring/strictures) • Achalasia

  9. Diagnosis Adenocarcinoma

  10. Adenocarcinoma Epidemiology: 5.69 / 100K in white males 0.74 / 100K in white females risk: smokers, high BMI, GERD, diet Not associated with alcohol Uncertain familial factors Endoscopy - fungating mass in distal esophagus Histology – poorly differentiated carcinoma lamina propia with infiltration into squamous epithelium

  11. Barium Esophagogram • Evaluation of swallowing function • Morphologic abnormalities of the pharynx/esophagus • Detection of esophageal carcinoma • Advantages: • availability • non-invasive • relatively inexpensive (costs $90-120) • high sensitivity (95%) • Disadvantages: • poor ability to demonstrate fine mucosal detail • cannot make dx for Barrett’s (pathologic sample needed) • radiation exposure

  12. Other Imaging • Esophagoscopy: visualize mucosa, obtain tissue samples • Costs $1000-$2000 • CT w/ contrast of chest, abdomen, pelvis: look for metastases • Costs: $2000-$3000 • Endoscopic USN: predicts depth of tumor invasion, extent of lymph node involvement • Costs: $13000-14000 • PET-CT: look for metastases • Costs: $4000-$5000

  13. Summary • First-line imaging for dysphagia is barium esophagogram • Follow-up studies include EGD for confirmation, CT/PET for staging • Treatment decisions based on TMN staging Questions?

  14. References • Enzinger PC, Mayer RJ. Esophageal Cancer. N Engl J Med. 2003 Dec 4;349(23):2241-52. • Epidemiology, pathobiology, and clinical manifestations of esophageal cancer. UptoDate 2009. • Harewood GC, Wiersema MJ. A cost analysis of endoscopic ultrasound in the evaluation of esophageal cancer. Am J Gastroenterol. 2002 Feb;97(2):452-8. • Levine MS, Stephen ER, Laufer I. Barium Esophagography: A study for All Seasons. Clin Gastroenterol Hepatol. 2008;6:11-25. • Radiographic images obtained from VA CPRS/Stentor • Cost information from Complete Guide to Medical Tests by H. Winter Griffin, MD • Case suggestion by Dr. Joshua Rubin

  15. AppendixAdditional Images

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