Dysphagia and Food Impaction: An Unexpected Etiology

Abstract

Malignant pseudoachalasia is a rare disease that presents with similar radiographic and manometric features as primary achalasia; however their clinical presentation may vary. Pseudoachalasia usually occurs in advanced age individuals with an acute onset and significant weight loss. This is the case of an 83-year-old man with a medical history of atrial fibrillation on chronic anticoagulation with warfarin, chronic kidney disease stage three and ischemic cerebrovascular accident, who was evaluated due to progressive dysphagia to solid food of four months in evolution. Three days prior to evaluation, the patient had an episode of food impaction after a solid meal in which he wasn't able to tolerate neither water nor his own pills. Symptomatology progressed developing nausea and vomiting of undigested food contents as well as a ten pound weight loss. Initial laboratories revealed normochromic, normocytic anemia and pre-renal azotemia. Chest computed tomography (CT) revealed dilation of esophagus with retained debris consistent with food impaction. Esophagogastroduodenoscopy revealed evidence of food impaction at mid esophagus, removed with overtube assistance for airway protection using a basket and Roth net. Upon stomach inspection, a mass like ulceration was observed at the distal body of the stomach, multiple biopsies were obtained, which latter confirmed moderately differentiated invasive gastric adenocarcinoma. Endoscopic ultrasound showed a hypoechoic lesion with infiltration of submucosa and muscularis propria layer of the gastric wall. without lymphadenopathies, for a tumor staging of T2N0M0. PET/CT showed no metastasis. Barium swallow revealed a proximal dilation with distal narrowing consistent with achalasia. Manometry was remarkable for aperistalsis and increased lower esophageal sphincter resting pressure. Anti-neuronal nuclear antibodies, Anti-Hu and Anti-Ach were normal. Final diagnosis of pseudoachalasia secondarily to infiltrative gastric adenocarcinoma causing myenteric plexus dysfunction at muscularis propria on distal body was made. Rare etiology since most common cause of pseudoachalasia is compression of the esophagus by an extraluminal mass at fundus or cardia. Due to poor functional status patient wasn't a surgical candidate and was started on chemotherapy with 5FU and cisplatin.