A 54-year-old man comes to the office with difficulty swallowing solids but not liquids for the past 3 months. The patient frequently has a sensation of food "sticking" within the chest, which is worse with foods such as meat and cheese. He has no choking, coughing, or vomiting while eating. Medical history is significant for gastroesophageal reflux disease for the past 6 years managed with antireflux therapy. The patient underwent endoscopy 6 months ago and was diagnosed with Barrett esophagus without dysplasia. The patient's vital signs are within normal limits. BMI is 38 kg/m2. Barium swallow reveals an area of symmetric, concentric narrowing affecting the distal esophagus. Which of the following best explains this finding?
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This patient with chronic gastroesophageal reflux disease (GERD) has esophageal dysphagia, which is characterized by normal initiation of a swallow (eg, no choking, coughing) followed by a sensation that food "sticks" within the chest. Difficulty swallowing solids but not liquids is characteristic of mechanical obstruction.
Common causes of mechanical obstruction in patients with GERD include the following:
Esophageal stricture, which is caused by reparative collagen deposition in response to esophageal mucosal damage caused by acidic gastric contents. Most strictures are not malignant. Imaging reveals generally symmetric, concentric narrowing in the distal esophagus.
Esophageal adenocarcinoma, which can occur in a small percentage of patients with Barrett esophagus (BE) (intestinal metaplasia in the distal esophagus). Imaging typically shows an asymmetrical and irregular narrowing of the distal esophagus.
This patient likely has an esophageal stricture, which can be treated through endoscopic dilation. Although he was diagnosed with BE, there is no dysplasia, and adenocarcinoma is unlikely due to the slow rate of malignant transformation of BE (<1% per year; this patient was diagnosed only 6 months ago) and inconsistent endoscopic findings of concentric, symmetric narrowing (Choice B).
(Choice A) Achalasia is a motility disorder. Unlike a disorder that causes mechanical obstruction (eg, esophageal stricture), achalasia presents with dysphagia to solids and liquids at onset, a feature not seen in this patient. Barium swallow typically shows aperistalsis, dilation of the esophagus proximal to the lower esophageal sphincter, and narrowing in a bird-beak pattern at the sphincter.
(Choice D) A hiatal hernia is a protrusion of the stomach above the diaphragm and can present with GERD (and related complications) due to an incompetent lower esophageal sphincter caused by anatomic distortion. However, barium swallow would show gastric folds protruding above the diaphragm.
(Choice E) Vascular rings are uncommon congenital anomalies in which aortic arch vessels encircle the trachea and/or esophagus. Esophageal narrowing is expected not in the distal esophagus, but rather more proximally at the level of the aortic arch.
Educational objective:
Esophageal stricture is a complication of chronic gastroesophageal reflux disease and is caused by reparative collagen deposition in response to acid damage. At onset, patients have progressive dysphagia to solids but not liquids. Endoscopic findings include concentric, symmetric narrowing of the distal esophagus.