Atypical Dysphagia With Corkscrew Esophagus and Panesophageal Pressurization

Patient Profile & Clinical Presentation

• Patient: 68-year-old patient

• Symptoms: Intermittent dysphagia to liquids and solids, painful thoracic spasms and intermittent vomiting.

• Weight Loss: Loss of approximately 15 kg.

Diagnosis Process

• CT Scan: 5 cm long circumferential thickening of the mid-thoracic esophagus.

• Endoscopy: Pseudo-tracheal aspect of the esophagus («trachealization») with multiple rings and no peristalsis.

• Biopsies: Normal without eosinophilic esophagitis.

• PET/CT: Suspicious 12 cm long esophageal fixation (SUV max 15.6).

• Echo-endoscopy: Thickening and fusion of wall layers, 36 to 39 cm from dental arch.

• High-Resolution Manometry: Impaired relaxation of LES, panesophageal pressurization pattern.

Therapeutic Process

• Initial Treatment: After multidisciplinary discussions, a first series of Botox injections was performed with slight beneficial effect on pain.

• Re-evaluation: Considering the atypical outcome, a new echo-endoscopy was performed showing a corkscrew aspect of the esophagus and a pseudo-diverticulization between 30 to 42 cm from dental arch.

• Surgical Treatment: Following a new board discussion, a myotomy was performed by thoracoscopic approach in prone position.

Follow-up

Six months later, the patient eats normally, with no pain, and is gaining weight.

Discussion Points

1. Diagnostic and therapeutic approach: Difficult problems regarding atypical dysphagia.

2. Pre-treatment evaluation: Imaging and endoscopic workup and its interpretation.

3. Choice of management: Endoscopic or surgical approach.

4. Long-term results

Discussion Leaders

Brice Gayet and Stéphane Bonnet, IMM, Paris, with a top level panel currently being assembled.

Panel for Discussion

Robert Bechara, Kingston, Canada | Stefan Mönig, Geneva, Switzerland | Marcelo Vela, Mayo Clinic, Scottsdale, AZ, USA | Bruno Zilberstein, Sao Paulo, Brazil