S2271 Dysphagia Aortica: An Achalasia Mimic and Pitfalls in Esophageal Manometry Interpretation

Abstract

Introduction: Dysphagia aortica is a rare clinical entity wherein compression of the esophagus is due to aneurysmal dilatation of the aorta, resulting in dysphagia symptoms. Approximately 70 cases of dysphagia aortica have been reported in literature; 9 of these have been in the US. Clinical attributes of dysphagia aortica include older age, spinal abnormalities, and hypertension. Case Description/Methods: This is an 82-year-old female with relevant history of prior ascending aortic aneurysm repair with known 54 mm thoracoabdominal aortic aneurysm (TAAA), mild to moderate dysphasia, hiatal hernia and GERD presented with a food impaction. EGD was performed for food bolus retrieval and revealed a tortuous esophagus with abnormal motility/spasticity in the middle and lower esophagus. Esophageal manometry revealed a median IRP of 12.2 and 60% ineffective swallows but was limited by the inability to advance the probe beyond 43 cm. The diagnosis of achalasia was made, and the patient underwent 3 botulinum toxin injections over the next year, but without significant relief of dysphagia. A repeat CT showed interval enlargement of TAAA to 60 mm at level of diaphragmatic hiatus which compressed the distal esophagus. Discussion: Dysphagia aortica is mostly attributed to aortic aneurysm, tortuosity or dissection. Symptoms include dysphagia, cough, sternal pain and weight loss. Clinicians must be aware that LES pressure may not be reliably differentiated from other contributors to intraluminal pressure such as crural diaphragm or TAAA. Therefore, a high index of suspicion must be maintained for dysphagia aortica when interpreting manometry based on patients’ clinical attributes and comorbidities. In contrast to previously reported literature, a localized high-pressure zone was not initially noted on manometry in our patient and subsequent CT imaging demonstrated extrinsic compression – adding to the subtle variations by which dysphagia aortica may represent a diagnostic conundrum.