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
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