S3414 Esophageal Dysfunction in Systemic Sclerosis: A Rare Etiology of Heartburn

Abstract

INTRODUCTION: Heartburn is a prevalent condition with obesity, old age, and smoking identified as common risk factors. Systemic sclerosis with esophageal involvement is a rare etiology. Here we present a case of systemic sclerosis which presented with the symptoms of heartburn and regurgitation. CASE DESCRIPTION/METHODS: A 40-year-old female patient presented to our clinic with complaints of persistent heartburn and regurgitation for the last 1 month. She had a past medical history of rheumatoid arthritis and systemic sclerosis. Her medications included methotrexate, leflunomide, and piroxicam. She was also given daily oxygen therapy for her lung complaints. For the past 6 months, she had on and off heartburn symptoms which were relieved by over the counter antacids. However, for the last 1 month, she had a persistent burning sensation in her chest and epigastric region. She also complained of regurgitation and occasional vomiting. These symptoms worsened after food intake and at night which caused her to avoid meals. There was no history of hematamesis, black-colored stools or dysphagia. Her vitals were normal. She walked with short steps, had skin tightness and conjunctival pallor. Her Hemoglobin was 9.8 g/dl with mean corpuscular volume 66 fL. Her endoscopy showed dilated esophagus proximal to stricture at the lower end of the esophagus (Figure 1). The lower third of the esophagus showed changes consistent with reflux esophagitis. Other positive findings included incompetent lower esophageal sphincter, hyperemic stomach mucosa and dilated second portion of the duodenum. Based on these findings, the patient was diagnosed as a case of peptic stricture most likely due to reflux esophagitis. Systemic sclerosis probably contributed to her esophageal problems. She was treated with high dose proton pump inhibitors and prokinetics. She was advised to elevate the head end of the bed and abstain from lying down immediately after her meals. Follow-up after 2 weeks showed improvement in her symptoms. DISCUSSION: Systemic sclerosis is a multisystem connective tissue disorder. Its pathogenesis revolves around inappropriate immunological responses which result in excessive collagen deposition in the skin and internal organs like the esophagus. Esophageal involvement is diagnosed by endoscopy and esophageal pH monitoring. This condition is usually managed by lifestyle changes and medical treatment by prokinetics and proton pump inhibitors.Figure 1.: Endoscopy image shows a dilated esophagus proximal to a stricture at the lower end of esophagus. The lower esophageal sphincter is also incompetent.