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Extragastroesophageal Malignancy-Associated Secondary Achalasia: A Rare Association of Pancreatic Cancer Rendering Alarm Manifestation.

Kim HM, Chu JM, Kim WH, Hong SP, Hahm KB, Ko KH - Clin Endosc (2015)

Bottom Line: For instance, pancreatic cancer was found in the case reported here; only four such cases have been reported in the literature.However, unresponsiveness to diverse conventional achalasia treatments led us to suspect secondary achalasia.An active search led to a diagnosis of pancreatic mucinous cystadenocarcinoma invading the gastric fundus and EG junction.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea.

ABSTRACT
Secondary achalasia or pseudoachalasia is a rare esophageal motor abnormality, which mimics primary achalasia; it is not easily distinguishable from idiopathic achalasia by manometry, radiological examination, or endoscopy. Although the majority of reported pseudoachalasia cases are associated with neoplasms at or near the esophagogastric (EG) junction, other neoplastic processes or even chronic illnesses such as rheumatoid arthritis can lead to the development of pseudoachalasia, for example, mediastinal masses, gastrointestinal (GI) tumors of the liver and biliary tract, and non-GI malignancies. Therefore, even if a patient presents with the typical findings of achalasia, we should be alert to the possibility of other GI malignancies besides EG tumors. For instance, pancreatic cancer was found in the case reported here; only four such cases have been reported in the literature. A 47-year-old man was admitted to our center with a 3-month history of dysphagia. His endoscopic and esophageal manometric findings were compatible with primary achalasia. However, unresponsiveness to diverse conventional achalasia treatments led us to suspect secondary achalasia. An active search led to a diagnosis of pancreatic mucinous cystadenocarcinoma invading the gastric fundus and EG junction. This rare case of pseudoachalasia caused by pancreatic carcinoma emphasizes the need for suspecting GI malignancies other than EG tumors in patients refractory to conventional achalasia treatment.

No MeSH data available.


Related in: MedlinePlus

Esophageal stent insertion to relieve dysphagia of secondary achalasia. Endoscopic image of an esophageal stent (uncovered, 5 cm; Taewoong Medical) placed across the esophagogastric junction into the proximal stomach.
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Figure 5: Esophageal stent insertion to relieve dysphagia of secondary achalasia. Endoscopic image of an esophageal stent (uncovered, 5 cm; Taewoong Medical) placed across the esophagogastric junction into the proximal stomach.

Mentions: A 47-year-old man was admitted to our hospital with a 3-month history of dysphagia and a resultant 15 kg weight loss in 3 months. The patient did not have any relevant medical history in the previous year, but he had complained of solid food dysphagia at first, which gradually aggravated to liquid food dysphagia. He also experienced intermittent hoarseness. On physical examination, his vital signs were found to be stable and though mild tenderness was found on his epigastrium, there was no palpable mass in the abdomen. To search for the cause of dysphagia, upper endoscopy was performed, revealing some fluid and food contents on the lower esophagus along with a mildly dilated esophagus (Fig. 1A, B); the endoscope met with severe resistance while passing through the EG junction, but the scope could be passed into the stomach (Fig. 1C). On esophageal manometric examination, the pressure of the lower esophageal sphincter was very high, accompanied by a low pressure of the esophageal body and some aperistaltic contractions, which is compatible with achalasia (Fig. 2). Considering the clinical impression of primary achalasia, we injected 0.5 mL of a solution containing 100 IU botulinum toxin (Botox; Allergan, Irvine, CA, USA) mixed with 2 mL normal saline into the EG junction in the 3, 6, 9, and 12 o'clock directions to relive dysphagia (Fig. 3). Failure to improve symptoms with botulinum toxin led us to perform up to 20 mm through the scope (TTS) esophageal balloon dilatation thrice for 30 seconds each (Cook Tri-Ex; Cook, Duluth, GA, USA) followed by 30 mm TTS ballooning. Considerable resistance to ballooning, which manifested as inefficiency, led us to obtain a chest/abdominal computed tomography (CT) scan to elucidate other possibilities of secondary achalasia. An abdominal CT scan was performed and revealed a 7.5 cm-sized multiple septated cystic pancreatic mass invading the area from the gastric body to the fundus. Minimal omental infiltration was found in the paracardiac area with some ascites in the pelvic cavity, suggesting peritoneal carcinomatosis (Fig. 4). A tumor tissue biopsy confirmed the diagnosis of pancreatic mucinous cyst adenocarcinoma. Although we placed an esophageal stent (uncovered, 5 cm; Taewoong Medical, Seoul, Korea) to relieve dysphagia (Fig. 5), and additionally administered gemcitabine-based chemotherapy (1,000 mg/m2 bovine serum albumin; Gemzar, Eli-Lilly, IN, USA), the patient died 5 months later.


Extragastroesophageal Malignancy-Associated Secondary Achalasia: A Rare Association of Pancreatic Cancer Rendering Alarm Manifestation.

Kim HM, Chu JM, Kim WH, Hong SP, Hahm KB, Ko KH - Clin Endosc (2015)

Esophageal stent insertion to relieve dysphagia of secondary achalasia. Endoscopic image of an esophageal stent (uncovered, 5 cm; Taewoong Medical) placed across the esophagogastric junction into the proximal stomach.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4522426&req=5

Figure 5: Esophageal stent insertion to relieve dysphagia of secondary achalasia. Endoscopic image of an esophageal stent (uncovered, 5 cm; Taewoong Medical) placed across the esophagogastric junction into the proximal stomach.
Mentions: A 47-year-old man was admitted to our hospital with a 3-month history of dysphagia and a resultant 15 kg weight loss in 3 months. The patient did not have any relevant medical history in the previous year, but he had complained of solid food dysphagia at first, which gradually aggravated to liquid food dysphagia. He also experienced intermittent hoarseness. On physical examination, his vital signs were found to be stable and though mild tenderness was found on his epigastrium, there was no palpable mass in the abdomen. To search for the cause of dysphagia, upper endoscopy was performed, revealing some fluid and food contents on the lower esophagus along with a mildly dilated esophagus (Fig. 1A, B); the endoscope met with severe resistance while passing through the EG junction, but the scope could be passed into the stomach (Fig. 1C). On esophageal manometric examination, the pressure of the lower esophageal sphincter was very high, accompanied by a low pressure of the esophageal body and some aperistaltic contractions, which is compatible with achalasia (Fig. 2). Considering the clinical impression of primary achalasia, we injected 0.5 mL of a solution containing 100 IU botulinum toxin (Botox; Allergan, Irvine, CA, USA) mixed with 2 mL normal saline into the EG junction in the 3, 6, 9, and 12 o'clock directions to relive dysphagia (Fig. 3). Failure to improve symptoms with botulinum toxin led us to perform up to 20 mm through the scope (TTS) esophageal balloon dilatation thrice for 30 seconds each (Cook Tri-Ex; Cook, Duluth, GA, USA) followed by 30 mm TTS ballooning. Considerable resistance to ballooning, which manifested as inefficiency, led us to obtain a chest/abdominal computed tomography (CT) scan to elucidate other possibilities of secondary achalasia. An abdominal CT scan was performed and revealed a 7.5 cm-sized multiple septated cystic pancreatic mass invading the area from the gastric body to the fundus. Minimal omental infiltration was found in the paracardiac area with some ascites in the pelvic cavity, suggesting peritoneal carcinomatosis (Fig. 4). A tumor tissue biopsy confirmed the diagnosis of pancreatic mucinous cyst adenocarcinoma. Although we placed an esophageal stent (uncovered, 5 cm; Taewoong Medical, Seoul, Korea) to relieve dysphagia (Fig. 5), and additionally administered gemcitabine-based chemotherapy (1,000 mg/m2 bovine serum albumin; Gemzar, Eli-Lilly, IN, USA), the patient died 5 months later.

Bottom Line: For instance, pancreatic cancer was found in the case reported here; only four such cases have been reported in the literature.However, unresponsiveness to diverse conventional achalasia treatments led us to suspect secondary achalasia.An active search led to a diagnosis of pancreatic mucinous cystadenocarcinoma invading the gastric fundus and EG junction.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea.

ABSTRACT
Secondary achalasia or pseudoachalasia is a rare esophageal motor abnormality, which mimics primary achalasia; it is not easily distinguishable from idiopathic achalasia by manometry, radiological examination, or endoscopy. Although the majority of reported pseudoachalasia cases are associated with neoplasms at or near the esophagogastric (EG) junction, other neoplastic processes or even chronic illnesses such as rheumatoid arthritis can lead to the development of pseudoachalasia, for example, mediastinal masses, gastrointestinal (GI) tumors of the liver and biliary tract, and non-GI malignancies. Therefore, even if a patient presents with the typical findings of achalasia, we should be alert to the possibility of other GI malignancies besides EG tumors. For instance, pancreatic cancer was found in the case reported here; only four such cases have been reported in the literature. A 47-year-old man was admitted to our center with a 3-month history of dysphagia. His endoscopic and esophageal manometric findings were compatible with primary achalasia. However, unresponsiveness to diverse conventional achalasia treatments led us to suspect secondary achalasia. An active search led to a diagnosis of pancreatic mucinous cystadenocarcinoma invading the gastric fundus and EG junction. This rare case of pseudoachalasia caused by pancreatic carcinoma emphasizes the need for suspecting GI malignancies other than EG tumors in patients refractory to conventional achalasia treatment.

No MeSH data available.


Related in: MedlinePlus