DysphagiaDysphagia

Student Name: Jack LiPeriod: 3 Date: 7/22/09

HistoryHistory• 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

Physical Exam and LabsPhysical 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

FindingsFindings• 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

ImagesImages

ImagesImages

ImagesImages

Differential DiagnosisDifferential Diagnosis• High

– Adenocarcinoma– Squamous cell carcinoma– Asymmetric scarring– Barrett’s esophagus

• Low– Schatzki’s ring– Reflux esophagitis (scarring/strictures)– Achalasia

DiagnosisDiagnosis

Adenocarcinoma

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

Barium EsophagogramBarium 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

Other ImagingOther 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

SummarySummary- 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?

ReferencesReferences• 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

AppendixAppendixAdditional ImagesAdditional Images