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Zorluk: ZorGastroenterology and Hepatology

A 68-year-old man presents to the clinic with a 4-month history of progressive dysphagia to both solid foods and liquids. He reports frequent episodes of regurgitating undigested, bland-tasting food shortly after meals and occasionally wakes up coughing at night. He has experienced an unintentional weight loss of 13 kg (28.6 lb) during this period. Medical history is significant for hypertension and a 45-pack-year smoking history. Vital signs are within normal limits. Physical examination reveals temporal wasting but is otherwise unremarkable. A barium esophagram demonstrates significant dilation of the proximal and mid-esophagus with a smooth, tapering 'bird's beak' appearance at the lower esophageal sphincter. Esophageal manometry shows aperistalsis of the esophageal body and absent relaxation of the lower esophageal sphincter. Upper gastrointestinal endoscopy reveals a normal-appearing esophageal mucosa; however, the endoscopist encounters firm resistance at the esophagogastric junction, and the endoscope cannot be advanced into the stomach despite gentle pressure. Which of the following is the most appropriate next step in management?

  1. Endoscopic ultrasonographyCevap
  2. B
    Laparoscopic Heller myotomy
  3. C
    Pneumatic balloon dilation
  4. D
    Botulinum toxin injection
  5. E
    24-hour ambulatory pH monitoring

Cevap

Endoscopic ultrasonography
The correct answer is endoscopic ultrasonography. This patient presents with symptoms and imaging (barium swallow 'bird's beak', manometric aperistalsis) that mimic primary achalasia. However, he exhibits classic 'red flags' for pseudoachalasia (a condition mimicking achalasia but caused by malignancy at the esophagogastric junction): older age, rapid onset of symptoms (<6 months), significant weight loss, and a history of heavy smoking. The definitive distinguishing factor is the upper endoscopy. In primary achalasia, the obstruction is functional due to a loss of inhibitory neurons; thus, an endoscope can easily overcome the sphincter tone and pass into the stomach with gentle pressure. In this patient, the endoscope encountered firm resistance, indicating a fixed structural lesion. Because infiltrating esophagogastric junction tumors (like adenocarcinoma) can grow submucosally, the mucosal surface may appear entirely normal. Therefore, endoscopic ultrasonography (or a CT scan of the chest and abdomen) is the most appropriate next step to visualize the submucosal layers and evaluate for an underlying malignancy.

Adım Adım Çözüm

1
Analyze the patient's symptoms and initial imaging.
Dysphagia to solids and liquids, regurgitation, and a 'bird's beak' appearance on barium swallow with aperistalsis on manometry are classic for an achalasia-like pattern.
To establish the primary physiological abnormality (lower esophageal sphincter failure to relax).
2
Evaluate for red flags differentiating primary achalasia from pseudoachalasia.
The patient has older age (>60), rapid symptom onset (4 months), profound weight loss (13 kg), and heavy smoking history, raising high suspicion for malignancy.
Primary achalasia typically presents in younger patients with a slow, gradual onset of symptoms over years.
3
Interpret the endoscopic findings.
The endoscope met firm resistance at the esophagogastric junction and could not pass. In primary achalasia (a functional obstruction), the endoscope passes easily with gentle pressure. Resistance indicates a mechanical obstruction, confirming pseudoachalasia.
To differentiate between functional spasm and structural blockade.
4
Determine the definitive next diagnostic step.
Because the mucosa appears normal, a submucosal tumor (e.g., adenocarcinoma) is highly likely. Endoscopic ultrasonography is required to visualize the submucosal layers and surrounding tissues.
To identify and stage the underlying malignancy causing the pseudoachalasia before any therapeutic intervention.

Anahtar Kavram

Pseudoachalasia caused by malignancy must be distinguished from primary achalasia by the presence of red flags (rapid onset, profound weight loss, older age) and the inability to pass an endoscope through the esophagogastric junction. Endoscopic ultrasound or CT is required for diagnosis.
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