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A9) Dysphagia and weight loss
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 52-year-old male presents to the clinic and reports unintentional weight loss due to difficulty swallowing both liquids and solids for the past year. He also reports chest pain that gets worse after eating. After eating, he also sometimes regurgitates food. The patient has visited his home country, Nicaragua, three times in the last two years.
Physical Exam
BP: 125/82, HR 70, RR 18, Temp 98.6F, O2 saturation 99%.
Cardiac: Retrosternal pain is not reproducible upon palpation. Heart rate and rhythm are regular. No murmurs, gallops, or rubs are auscultated.
Abdomen: Soft, nondistended, and non-tender.
Labs
Cardiac enzymes negative and EKG unremarkable.
Provisional Diagnosis
Select the Dx you believe is most appropriate
The patient’s dysphagia to both solids and liquids with chest pain and regurgitation are concerning for an esophageal dysmotility disorder, like diffuse esophageal spasm or achalasia. Achalasia is more likely considering the recent travel to Nicaragua, where Typanosoma cruzi, a causative agent, is endemic.
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Potential Acuity
What is your assessment of the likely acuity for this patient?
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The patient’s condition is chronic and not immediately life-threatening. Therefore, they require routine workup.
First Imaging Study
What is the first imaging study you will order?
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.
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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?
There is a “bird beak” esophagus that occurs due to failure of relaxation of the lower esophageal sphincter. This leads to the standing column of barium.
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?
The diagnosis should be confirmed with esophageal manometry, which is the gold standard test for the diagnosis of DES. The results are not shown for the purposes of this case. Absence of adequate peristaltic contractions and high resting lower esophageal sphincter with failure to relax after swallowing are indicative of achalasia.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
The patient’s presentation is most consistent with achalasia. The barium swallow study showed 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?
The patient’s condition is chronic and not immediately life-threatening. Therefore, they require routine workup.
Assessment and Plan
Please provide your assessment and plan for this patient
This patient is a 52-year-old male presenting with symptoms and barium swallowing imaging findings consistent with achalasia. Gastroenterology should be consulted to perform a manometry and to evaluate for treatment, such as pneumatic dilation, Heller myotomy, or peroral endoscopic myotomy, depending on the results.
Lessons Learned:
- Achalasia occurs due to degeneration of the myenteric plexus ganglion cells, leading to failure to relax the lower esophageal sphincter.
- Achalasia is most often idiopathic. However, it may be caused by trypanosoma cruzi, which destroys the myenteric plexus.
- Achalasia may appear on a barium swallow study as a “bird beak” esophagus and a standing column of barium due to failure of relaxation of the lower esophageal sphincter. Furthermore, there would be minimal esophageal contractions.
- Standard treatment often involves pneumatic dilation, Heller myotomy, or peroral endoscopic myotomy. Botulinum toxin injection may be performed in patients who are not surgical candidates.
Socioeconomic Factors: Achalasia has been shown to be more common among patients residing in higher-income areas and in metropolitan areas. This may reflect detection bias, as large hospitals and teaching hospitals may be more properly equipped for diagnosing achalasia.
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