S3552 A Unique Presentation of Esophageal Cancer as a Mysterious Analgesic-refractory Chest Pain

Abstract

Introduction: Chest pain has a wide differential diagnosis. It is important for clinicians to recognize the atypical presentations of esophageal carcinomas as chest pain. We report a case of a patient with esophageal carcinoma resistant to analgesics who presented with chest pain only Case Description/Methods: A 61-year-old male was presented to the emergency department with right-sided chest pain for eight days. It was a severe, sudden onset, non-radiating, and sharp in nature, which increased by deep breathing without relieving factors. The exam was unremarkable but for the heart rate of 119 bpm. The Lab findings, cardiac enzymes, and chest radiographs all were normal. ECG was consistent with sinus tachycardia. CT angiogram and the duplex US of the abdomen were without significant findings. Abdominal CT showed thickened gastroesophageal junction concerning an underlying neoplasm with lymphadenopathy and invasion of the pancreatic body. Esophagogastroduodenoscopy findings showed a large, ulcerated, noncircumferential mass just below the GE junction at 45 cm with no bleeding. Another significant, partially obstructing, noncircumferential ulcerating mass was found in the distal esophagus, extending from 39 cm to 45cm from the incisors along with esophageal mucosal changes suspicious for long-segment, Barrett's esophagus, and moderately differentiated adenocarcinoma of the GE junction, clinically categorized as stage IV, T4 N3 MX. The patient opted for palliative chemotherapy Discussion: Metastatic cancer can masquerade as retrosternal chest pain. About 74% of these patients present with dysphagia, 17 % report odynophagia, 57% report weight loss, and 21% report long-standing GERD. But when the patient presents with retrosternal or right upper abdominal pain, it usually reflects unresectable and extensive disease. Physicians should recognize that persistent pain disproportionate to the exam findings is concerning for the possibility of unresectable extensive malignant disease.Figure 1.: EGD findings: The blue dot for the large, ulcerated, noncircumferential mass just below the GE junction at 45 cm without bleeding.