WIDI - A11) Dysphagia and chest pain

A11) Dysphagia and chest pain

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 48-year-old woman with a past medical history of GERD and AV block requiring pacemaker placement presents to the clinic with a one-year history of intermittent non-exertional retrosternal chest pain. The patient has also been having difficulty swallowing solids and liquids with regurgitation, particularly when they are hot or cold. During these periods, she also regurgitates food. The pain is not associated with exercise. She denies any shortness of breath.

Physical Exam

BP: 122/84, HR 78, RR 18, Temp 98.6, O2 saturation 96%. Cardiac: Retrosternal pain is not reproducible upon palpation. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are regular. No murmurs, gallops, or rubs are auscultated. S1 and S2 are heard and are of normal intensity. Abdomen: Soft, nondistended, and non-tender.

Labs

Cardiac enzymes, EKG, and stress test are unremarkable.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Esophageal motility disorder

Esophageal adenocarcinoma

Acute coronary syndrome

This patient’s retrosternal chest pain, dysphagia, and regurgitation are most consistent with a motility disorder of the esophagus. Given the normal EKG, stress test, and a lack of elevated cardiac enzymes, Acute coronary syndrome is unlikely. Achalasia occurs when the LES fails to relax and can be associated with coughing at night and weight loss.

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Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

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This chronic condition is not immediately life-threatening and warrants routine workup.

First Imaging Study

What is the first imaging study you will order?

CT neck and chest

Barium Swallow Fluoroscopy

MRI chest

A Barium swallow is the initial imaging modality of choice to evaluate the pharynx and esophagus. It can provide structural and functional evaluation of the esophagus.

View ACR Appropriateness Criteria

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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Barium swallow study

What best describes the findings on the barium swallow study?

Constricted lower esophageal sphincter with a “bird beak appearance”

Corkscrew appearance of the distal esophagus

Normal peristalsis

There is a “corkscrew” appearance of the esophagus secondary to tertiary, disorganized, simultaneous contractions.

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Second Imaging Study

What is the next imaging study you will order?

CT neck and chest

MRI chest

None

The diagnosis should be confirmed with esophageal manometry, which is the gold standard test for the diagnosis of DES. Findings on the manometry would reveal simultaneous esophageal contractions in 20% or greater of water swallows mixed with some normal peristalsis. In addition, manometry can further evaluate the function of the gastro-esophageal junction.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Achalasia

Diffuse Esophageal Spasm

Acute Coronary Syndrome

The patient’s presentation is most consistent with diffuse esophageal spasm. The barium swallow study revealed a corkscrew or rosary bead appearance of the esophagus from tertiary contractions. Achalasia would show a “bird beak” esophagus with minimal esophageal contractions and a standing column of barium. ACS is unlikely given the normal labs, EKG, and physical exam.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient requires routine workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

The patient is a 48-year-old woman presenting with symptoms and barium swallow imaging findings consistent for diffuse esophageal spasm. Manometry should be performed to confirm the diagnosis. For treatment, she may undergo a trial of calcium channel blockers or nitrates to reduce the severity of the spasm.

Lessons Learned:
- A barium swallow may be performed in patients with dysphagia to assess the structure and function of the pharynx and esophagus.
- A corkscrew or rosary bead appearance of the esophagus on barium swallow is indicative diagnosis of DES.
- Follow up testing with manometry should be conducted in DES patients to confirm the diagnosis and rule out achalasia. This is an important part of the workup as the barium swallow is not highly sensitive or specific for diffuse esophageal spasm. For example, less than 5% of patients with diffuse esophageal spasm have a “corkscrew esophagus” on the barium swallow study. The barium swallow study more often presents with non-peristaltic contractions.
- Calcium channel blockers and nitrates may alleviate symptoms. If the patient has symptoms refractory to medical treatment, Botox injections may be indicated to cause temporary paralysis of the esophageal body. The last option would be an esophageal myotomy. However, this is considered when other treatments don’t work due to lack of long-term studies evaluating patient outcomes.
- Diffuse esophageal spasm may present similarly to angina considering that it is relieved by nitrates.

Socioeconomic Factors:
- Diffuse esophageal spasm is more likely to occur in obese patients since it has an association with hyperlipidemia, hyperglycemia, and hypertension. Patients with low-income who live in areas with poor access to nutritional foods may be more likely to have this diagnosis.
- Older age and psychiatric conditions like anxiety/depression are other common risk factors in the development of diffuse esophageal spasm.

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