An Atypical Case of Dysphagia: Left Atrial Enlargement

Abstract

Background: Dysphagia in the elderly is often due to oropharyngeal or esophageal causes. Dysphagia due to cardiac etiology is an uncommon diagnosis.1 We present a case of dysphagia as a result of extrinsic esophageal compression secondary to left atrial enlargement. Case: A 93 year old male with a PMH of atrial fibrillation on Rivaroxaban and a remote history of throat cancer status post radiation twenty years prior presented with hypoxia and hypotension after an aspiration event. Medical history also included HFpEF (EF 55%), valvular heart disease (Aortic Stenosis and Mitral Regurgitation) and coronary artery disease status post coronary artery bypass grafting (CABG) in 1998. Initial Chest X-Ray showed multifocal airspace disease in right upper and bilateral lower lobes as well as cardiomegaly (Figure 1). He was initially admitted to the ICU for aspiration pneumonia and septic shock requiring pressor support, then transferred to the medical floors after stabilization. Modified Barium Swallow study showed no evidence of laryngeal penetration or aspiration, yet patient continued to have episodes of post-prandial emesis during hospitalization. Endoscopy revealed incidental Schatzki ring at the gastroesophageal junction but was otherwise normal. Full Barium Swallow study revealed marked esophageal dysmotility with evidence of extrinsic compression on the distal portion of esophagus, resulting in delayed emptying of the proximal esophagus. CT Chest revealed compression of the esophagus secondary to left atrial enlargement (Figure 2). Cardiology evaluated patient and transthoracic echocardiogram confirmed left atrial dilatation and elevated filling pressures. Patient noted to have some symptomatic improvement with gentle diuresis and options for PEG tube were discussed, though not pursued as this was not in line with patient's goals of care.1777_A Figure 1. Initial CXR showing cardiomegaly and multifocal airspace disease1777_B Figure 2. CT Chest revealing atrial compression of esophagusDiscussion: Initial evaluation and management of dysphagia in the elderly begins with a comprehensive history and physical exam. This case demonstrates that when preliminary laboratory and imaging workup is unrevealing, re-assessing the anatomic location of swallowing dysfunction can help to provide a diagnostic clue. While cardiovascular dysphagia is uncommon, it should be on the differential in patients with risk factors for left atrial enlargement.