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Pseudoachalasia: Still a Tough Clinical Challenge.

Jia Y, McCallum RW - Am J Case Rep (2015)

Bottom Line: Further investigations finally uncovered esophageal adenocarcinoma, thus making our patient an example of the entity "pseudoachalasia".Pseudoachalasia secondary to an esophageal malignancy should be suspected when dysphagia progresses despite technically well-performed pneumatic dilations, and is particularly suspicious in the setting of an elderly patient with marked weight loss.Endoscopic ultrasound is a new diagnostic tool for detecting and staging malignancy by obtaining diagnostic tissue and allowing appropriate therapy to be planned.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, TX, USA.

ABSTRACT

Background: Treatment of achalasia is focused on decreasing the resting lower esophageal sphincter by either pneumatic dilation or surgical myotomy. When patients symptomatically relapse after one or more pneumatic dilations, then one explanation is to consider the possibility of pseudoachalasia as the diagnosis.

Case report: We present a rare case of an elderly patient with a presentation of chronic dysphagia and severe weight loss, who had diagnostic findings consistent with achalasia, and who also responded very well to a series of pneumatic dilations, but for only brief intervals. Further investigations finally uncovered esophageal adenocarcinoma, thus making our patient an example of the entity "pseudoachalasia".

Conclusions: Pseudoachalasia secondary to an esophageal malignancy should be suspected when dysphagia progresses despite technically well-performed pneumatic dilations, and is particularly suspicious in the setting of an elderly patient with marked weight loss. Endoscopic ultrasound is a new diagnostic tool for detecting and staging malignancy by obtaining diagnostic tissue and allowing appropriate therapy to be planned.

No MeSH data available.


Related in: MedlinePlus

Endoscopic ultrasound (EUS) identified a hypoechoic mass in the lower third of the esophagus, encountered at 35 cm from the incisors and extended to 38 cm which was the furthest the echoendoscope could be advanced due to the stenosis. The endosonographic borders were irregular, and a T3 lesion with multiple benign-appearing lymph nodes was detected. EUS guided biopsies showed poorly differentiate adenocarcinoma.
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f4-amjcaserep-16-768: Endoscopic ultrasound (EUS) identified a hypoechoic mass in the lower third of the esophagus, encountered at 35 cm from the incisors and extended to 38 cm which was the furthest the echoendoscope could be advanced due to the stenosis. The endosonographic borders were irregular, and a T3 lesion with multiple benign-appearing lymph nodes was detected. EUS guided biopsies showed poorly differentiate adenocarcinoma.

Mentions: Because of the endoscopic findings of irregular and inflamed tissue present proximal to the LES suggesting a mass effect together with the pneumatic dilation experience as well as the chest CT findings in the distal esophagus, an upper endoscopic ultra-sound (EUS) was performed 2 weeks later, to rule out the possibility of underlying cancer of the esophagus that could explain his refractoriness to the dilations. EUS identified a hypoechoic mass in the lower third esophagus and several hypoechoic lymph nodes with poorly defined margins (Figure 4). The mass lesion was circumferential with irregular borders. There was one image that the mass appeared to protrude through the muscularis propria (layer 4) with intact interface between the mass and the adjacent structures. This was staged as T3 N0 Mx by endosonographic criteria. The biopsies of the mass indicated poorly differentiated adenocarcinoma. Tumor cells were diffusely positive for low molecular weight cytokeratin, focally positive for cytokeratin-7, and negative for high molecular weight cytokeratin, cytokeratin-20, P63, and leukocyte common antigen immunostains. This tumor is most compatible with poorly differentiated adenocarcinoma as the primary rather than metastatic tumor from the previous colon cancer. The adenocarcinoma was presumed to have developed in the setting of Barrett’s esophagus. Patient had a PET scan which indicated no other metastasis. As a preventive measure to overcome any obstruction which could occur with the radiation therapy being planned preoperatively, the patient underwent esophageal stent placement and his nutrition status improved with ability to tolerate soft foods. He is currently being managed by the oncologist for his esophageal cancer with radiation and chemotherapy before surgery as the final goal.


Pseudoachalasia: Still a Tough Clinical Challenge.

Jia Y, McCallum RW - Am J Case Rep (2015)

Endoscopic ultrasound (EUS) identified a hypoechoic mass in the lower third of the esophagus, encountered at 35 cm from the incisors and extended to 38 cm which was the furthest the echoendoscope could be advanced due to the stenosis. The endosonographic borders were irregular, and a T3 lesion with multiple benign-appearing lymph nodes was detected. EUS guided biopsies showed poorly differentiate adenocarcinoma.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4630955&req=5

f4-amjcaserep-16-768: Endoscopic ultrasound (EUS) identified a hypoechoic mass in the lower third of the esophagus, encountered at 35 cm from the incisors and extended to 38 cm which was the furthest the echoendoscope could be advanced due to the stenosis. The endosonographic borders were irregular, and a T3 lesion with multiple benign-appearing lymph nodes was detected. EUS guided biopsies showed poorly differentiate adenocarcinoma.
Mentions: Because of the endoscopic findings of irregular and inflamed tissue present proximal to the LES suggesting a mass effect together with the pneumatic dilation experience as well as the chest CT findings in the distal esophagus, an upper endoscopic ultra-sound (EUS) was performed 2 weeks later, to rule out the possibility of underlying cancer of the esophagus that could explain his refractoriness to the dilations. EUS identified a hypoechoic mass in the lower third esophagus and several hypoechoic lymph nodes with poorly defined margins (Figure 4). The mass lesion was circumferential with irregular borders. There was one image that the mass appeared to protrude through the muscularis propria (layer 4) with intact interface between the mass and the adjacent structures. This was staged as T3 N0 Mx by endosonographic criteria. The biopsies of the mass indicated poorly differentiated adenocarcinoma. Tumor cells were diffusely positive for low molecular weight cytokeratin, focally positive for cytokeratin-7, and negative for high molecular weight cytokeratin, cytokeratin-20, P63, and leukocyte common antigen immunostains. This tumor is most compatible with poorly differentiated adenocarcinoma as the primary rather than metastatic tumor from the previous colon cancer. The adenocarcinoma was presumed to have developed in the setting of Barrett’s esophagus. Patient had a PET scan which indicated no other metastasis. As a preventive measure to overcome any obstruction which could occur with the radiation therapy being planned preoperatively, the patient underwent esophageal stent placement and his nutrition status improved with ability to tolerate soft foods. He is currently being managed by the oncologist for his esophageal cancer with radiation and chemotherapy before surgery as the final goal.

Bottom Line: Further investigations finally uncovered esophageal adenocarcinoma, thus making our patient an example of the entity "pseudoachalasia".Pseudoachalasia secondary to an esophageal malignancy should be suspected when dysphagia progresses despite technically well-performed pneumatic dilations, and is particularly suspicious in the setting of an elderly patient with marked weight loss.Endoscopic ultrasound is a new diagnostic tool for detecting and staging malignancy by obtaining diagnostic tissue and allowing appropriate therapy to be planned.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, TX, USA.

ABSTRACT

Background: Treatment of achalasia is focused on decreasing the resting lower esophageal sphincter by either pneumatic dilation or surgical myotomy. When patients symptomatically relapse after one or more pneumatic dilations, then one explanation is to consider the possibility of pseudoachalasia as the diagnosis.

Case report: We present a rare case of an elderly patient with a presentation of chronic dysphagia and severe weight loss, who had diagnostic findings consistent with achalasia, and who also responded very well to a series of pneumatic dilations, but for only brief intervals. Further investigations finally uncovered esophageal adenocarcinoma, thus making our patient an example of the entity "pseudoachalasia".

Conclusions: Pseudoachalasia secondary to an esophageal malignancy should be suspected when dysphagia progresses despite technically well-performed pneumatic dilations, and is particularly suspicious in the setting of an elderly patient with marked weight loss. Endoscopic ultrasound is a new diagnostic tool for detecting and staging malignancy by obtaining diagnostic tissue and allowing appropriate therapy to be planned.

No MeSH data available.


Related in: MedlinePlus