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A10) Dysphagia to solid food
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with dysphagia.
- Review the DDx considerations in a patient with dysphagia.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with dysphagia.
History
A 45-year-old female presents to the clinic with 3 months of gradually worsening dysphagia. She reports no difficulty swallowing liquids, but notes that she has significant difficulty swallowing solids to the point that her attempts at swallowing food frequently result in nasopharyngeal regurgitation. She denies odynophagia.
Physical Exam
BP: 127/80, HR 89, RR 18, Temp 37C, O2 saturation 100%.
General: Pallor. HEENT: Conjunctival pallor, atrophic glossitis, angular cheilitis. Extremities: koilonychia. Neck: No thyromegaly.
Labs
Hgb: 8.8 g/dL (ref. range: 11.9 to 14.8g/dL)
MCV: 67 fL (ref. range: 82.5 to 98)
Peripheral smear: hypochromic and microcytic RBCs
Serum iron test: Iron: 25 μg/dL (ref. range: 60-170 μg/dL)
TIBC: 470 μg/dL (ref. range: 240 to 450 mcg/dL).
Serum ferritin: 4 μg/L (ref. range: 11-307 μg/L)
Provisional Diagnosis
Select the Dx you believe is most appropriate
The patient most likely has Plummer Vinson syndrome considering the risk factors (middle-aged female), dysphagia to solids, and iron deficiency anemia.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
Well done. You were correct
The patient requires routine workup as this condition is chronic and not immediately life-threatening.
First Imaging Study
What is the first imaging study you will order?
Upper GI fluoroscopy is the best initial imaging modality to evaluate for esophageal webs in the gastrointestinal tract.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
Fluoro GI esophogram
The esophagus is partially occluded.
An esophageal web in the hypopharynx occludes the esophagus by approximately 75%.
The distal esophagus demonstrates abnormal contractions.
The esophagus distal to the web appears normal and without dysmotility.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
No further imaging is needed as the diagnosis is strongly suspected with the GI esophagram.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
The patient has both iron deficiency anemia and dysphagia caused by an anterior proximal esophageal web. This is consistent with Plummer Vinson syndrome.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient requires routine workup as this condition is not immediately life-threatening.
Assessment and Plan
Please provide your assessment and plan for this patient
This patient is a 45-year-old female likely presenting with Plummer Vinson Syndrome. She will benefit from iron supplementation. She will be referred to gastroenterology for evaluation for a definitive diagnostic and therapeutic upper endoscopy.
Lessons Learned:
- Plummer Vinson syndrome is marked by a triad of iron deficiency anemia, dysphagia of solid foods, and presence of proximal esophageal webs.
- The diagnosis should be suspected in patients with known or suspected iron deficiency anemia who develop painless dysphagia of solids, and is confirmed with evidence of upper esophageal webbing on fluoroscopy or upper endoscopy.
- The condition may be treated with iron supplementation. If the symptoms are severe, if esophageal web persists, or if dysphagia does not improve, a therapeutic upper endoscopy can be performed. Usually, when an endoscope is inserted, the esophageal web ruptures. If it does not or is still occlusive, an esophageal dilation may be performed.
Socioeconomic Factors: Nutritional deficiencies, including iron deficiency, are seen more commonly in populations of low socioeconomic status.
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