Clinical Image
Gnarly Esophagus
Ara Kardashian* and Williamson Strum
Department of Gastroenterology, Scripps Clinic Torrey Pines, 10666 N. Torrey Pines Rd, N203 La Jolla, CA 92037, USA
*Corresponding author: Ara Kardashian, Department of Gastroenterology, Scripps Clinic Torrey Pines, 10666 N. Torrey Pines Rd, N203 La Jolla, CA 92037, USA
Published: 24 Apr, 2017
Cite this article as: Kardashian A, Strum W. Gnarly
Esophagus. Clin Surg. 2017; 2: 1427.
Clinical Image
A 78-year-old woman with diastolic heart failure, hypertension, abdominal aortic aneurysm, severe spinal stenosis and cervical and thoracic myelopathy presented with a 4-years history of dysphagia to both solids and liquids. The symptoms were worse with dense foods and cold liquids, but occurred with all meals. Sensation of sticking was below the sternal notch. Associated symptoms included occasional nausea, but no vomiting or odynophagia. Over the past one year, she lost 15 pounds unintentionally. She underwent double contrast barium upper gastrointestinal study which showed a severely tortuous esophagus with poor motility and poor emptying (Figure A) and identified a large hiatal hernia. Endoscopic evaluation was performed to identify any areas of focal stricture which might be dilated. A 10-cm hiatal hernia in addition to a corkscrew esophagus was confirmed with no focal strictures (Figure B). The distal esophagus had three 90-degree angulations. The patient’s course was complicated by worsening neurological and spinal issues eventually confining her to a wheelchair. Her findings were radiographically and endoscopically consistent with diffuse esophageal spasm; esophageal manometry was not performed. Conservative treatment was advised.
Discussion
Treatment for esophageal motility disorders is aimed at the main symptoms of dysphagia and
chest pain. Targets include underlying gastroesophageal reflux disease, spastic or motility etiologies,
or visceral hypersensitivity. Varying degrees of evidence exist for use of proton pump inhibitors
(omeprazole, lansoprazole and rabeprazole), calcium channel blockers (diltiazem, nifedipine),
anxiolytics (trazadone), nitrates, phosphodiesterase inhibitors, theophylline, and imipramine among others. Botulinum toxin injection may provide symptom
relief, particularly from dysphagia. Given the anatomic features
of this patient’s esophagus, we did not feel that this would provide
sufficient benefit [1].
Pneumatic dilation may provide symptomatic relief from
focal strictures. Surgical interventions, including long esophageal
myotomy with proximal extension, are largely reserved for refractory
symptoms in patients with anatomically straight esophagus.
Treatment options for a severely angulated esophagus, as in this case,
are more limited. The possibilities include repair of the hiatal hernia
to partially straighten the esophagus and placement of a percutaneous
gastric feeding tube to bypass the obstruction. We prescribed for her a
conservative approach with a soft diet, small meals, and maintaining
an upright posture for at least one hour after meals. Over the last 30
months she has been able to tolerate soft foods and liquids and has
maintained her weight [2].
Figure A
Figure A
Contrast barium upper gastrointestinal study which showed a severely tortuous esophagus with poor
motility and poor emptying.
Figure B
Figure B
A corkscrew esophagus was confirmed with no focal strictures.