2018-02-26 19:35:43 UTC

Image Challenge: An Extremely Rare Cause of Dysphagia

Feb. 26, 2018

What caused a patient one-month history of progressive dysphagia when laboratory data showed no changes, like anemia or increased inflammatory parameters?

Gastroenterology Clinical Image Challenge: A 52-year-old woman presented to our department with a one-month history of progressive dysphagia for solids and weight loss (less than 10 percent of total weight). Her past medical history included cigarette smoking (15 pack-years) without medication, alcohol or drug consumption, nor familiar risk factors. The patient denied other symptoms like anorexia, nausea, heartburn, retrosternal chest pain, abdominal pain or gastrointestinal bleeding. On physical examination, she presented with a global decrease of the breath sounds. Laboratory data had no changes, like anemia or increased inflammatory parameters. Upper endoscopy revealed extensive submucosal blebs that collapsed with insufflation and were distributed over the esophagus circumference, especially in the medial and distal portions (Figure), without involvement of the stomach or duodenum. To confirm and complete this rare diagnose, a computed tomography (CT) scan of the chest was performed showing intramural gas within the wall of the esophagus and an extensive pulmonary emphysema (Figure).

The patient started oral metronidazole, 500 mg three times per day and ceased smoking. After two weeks of treatment, the patient was asymptomatic. Upper endoscopy, after one month of therapy, showed substantial improvement of the esophageal lesions. Some residual lesions were also treated using an endoscopy injection needle to “bust” the blebs (Figure). After six months of follow-up, the patient remains asymptomatic.

What is the diagnosis?

To find out the diagnosis, read the full case in Gastroenterology or download our Clinical Image Challenge app through AGA App Central, which features new cases each week. Sort and filter by organ, most popular or favorites. AGA App Central is available in both the Apple App Store and Google Play.