Linitis Plastica Presenting as Dysphagia Thought to Be Pseudoachalasia

Abstract

A 79 yr old M with past medical history of Barrett's esophagus s/p ablation presents with progressive dysphagia to solid foods. EGD showed stenosis at the GEJ, no tumor seen, but firm stricture. Biopsies showed unremarkable mucosa, negative for H. Pylori, but concern for extrinsic compression and congestive gastropathy. CT did not show any masses. Barium esophagram showed tapering of esophagus to the GEJ with a ‘bird's beak appearance. Manometry was confounded by a second high pressure zone beneath LES concerning for probe coiling. Manometry did not clearly meet any Chicago criteria. Possible diagnosis of achalasia type II questioned due to elements of preserved peristalsis. Repeat EGD again demonstrated severe stenosis, and a dilated esophagus. Biopsies were repeated which demonstrated no abnormalities. The patient was referred to thoracic surgery for surgical correction of achalasia. Third EGD with sequential dilation 21-33Fr dilators. Subsequently during admission for TIA, he had worsening dysphagia and CT chest demonstrated a mild thickening of the distal esophagus, previously seen but not reported. Repeat EGD again noted a marked narrowing that could not be traversed with standard endoscope but crossed with pediatric endoscope. In the stomach there were diffusely thickened folds and poor distensibility. EUS demonstrated irregular thickening of the mucosal layers and submucosal layers measuring 12mm thickness extending from the GEJ throughout the stomach to antrum. No lymphadenopathy noted. Biopsies demonstrated poorly differentiated carcinoma, immunostains were positive for AE1/3 and negative for CD45. Ki67 is positive in ˜70% tumor cells. PET scan showed widespread bone metastasis and hypermetabolic uptake in relation to the gastric mucosa. We describe a rare case of linitis plastica presenting as pseudoachalasia. However, the accuracy of endoscopy ranges widely, depending on the gross tumor growth pattern and the anatomic location of the tumor, with a sensitivity of only 33-73% observed in linitis plastica patients. Imaging and early endoscopy were concerning for achalasia, particularly in the setting of pathognomonic presence of “bird's beak” on barium swallow. Was questioned by manometry, however study had some uncertainty due to concern for possible coiling of the probe. This case serves to highlight the importance of EUS when endoscopy, imaging, and manometry are inconsistent.2969_A Figure 1 No Caption available.2969_B Figure 2 No Caption available.