Dysphagia: The Primary Indicator of Esophageal Compression by a Pericardial Effusion

Abstract

Introduction: Dysphagia is a relatively common symptom seen in late adulthood and can be classified as oropharyngeal or esophageal. Esophageal dysphagia typically presents due to scarring from acid reflux, strictures within the lumen, a tumor causing obstruction or an infection causing inflammation. A rare occurrence of dysphagia is reported here as an outcome of extrinsic compression of the esophagus by a large pericardial effusion. Case: A 61-year-old male with a history of DM, epilepsy, schizophrenia, vertigo and hyperlipidemia presented with an episode of hemoptysis and dysphagia for 3 weeks duration. Although this was the first account of hemoptysis, he admitted to a dry cough for a few months. He noted his dysphagia was predominantly to solids and unless he ate slowly, he would regurgitate. He denied any fever, shortness of breath, chest pain, weight loss or night sweats. On initial examination the patient was an obese male with stable vitals except for a slightly low oxygen saturation of 94%. Inspection of the neck revealed no masses. On auscultation, heart sounds were difficult to appreciate. Labs initially revealed an elevated WBC of 15.3, platelet count of 110, a blood sugar of 222 and the remaining results were within normal limits. Chest X-Ray showed infra-hilar infiltrates suggesting pneumonia and cardiomegaly. Modified barium swallow was negative. An esophagogastroduodenoscopy revealed mild extrinsic compression in the mid-esophagus but no strictures. CT of the chest showed a large pericardial effusion of 3.3 cm compressing the esophagus and chronic atelectasis with small bilateral pleural effusions. An echocardiogram confirmed a worsening pericardial effusion from 1 year previous and a dropping left ventricular ejection fraction (40-45% to 20-25%). Initial option for treatment was a pericardial window, but a cardiac catheterization revealed 2-vessel CAD with left main involvement. The patient ended up having a CABG and having his pericardial effusion drained. Follow up echocardiogram one month later revealed no pericardial effusion and a complete resolve of his dysphagia. Discussion: While there are documented cases of pericardial effusion resulting in compression of the esophagus, it is a rare occurrence. This case emphasizes that while dysphagia is often an esophageal complaint, the origin of the symptom may be non-GI and communication between GI and cardiac specialists is essential.