Symptomatic Esophageal Motor Dysfunction Decades after Radiation Therapy

Abstract

Purpose: A 72-year-old Caucasian woman was first seen at our university based gastroenterology clinic in August 2011 for 2 years history of progressively worsening difficulty in swallowing solids and cold liquids. Patient reported that food and liquid got stuck at the level of the middle of the neck after swallowing with regurgitation of material within a few minutes. She denied any odynophagia, hematemesis, melena, hematochezia, heartburn, or weight loss. No nocturnal symptoms, halitosis or regurgitation at night. She was treated in 1980 for thyroid cancer with surgery and radiation therapy. Physical examination revealed a healthy woman, and there were no skin changes, adenopathy or organomegaly. An EGD done in October 2011 was normal and no stricture was seen. A modified barium swallow done previously at an outside facility revealed impaired peristalsis and delayed passage of barium from the esophagus to the stomach worse with solid consistencies suggestive of esophageal dysmotility. An esophageal manometry was then performed which revealed ineffective esophageal peristalsis with low amplitude contractions (<40 mmHg) in the body of esophagus. The patient did not have clinical symptoms suggestive of systemic sclerosis and serologic testing including ANA, anti- SCL70 antibody, and anti-centromere antibody was negative. The patient was diagnosed as esophageal motor dysfunction due to radiation therapy. Radiographic studies have demonstrated asymptomatic esophageal motor abnormalities shortly after radiation therapy but clinical aspects of these motor findings have not been described before and neither have manometric studies been performed in this setting. Symptomatic esophageal motor abnormalities, unlike acute esophagitis and strictures, are rare complications after radiation therapy. This is only the second report of such a case in the medical literature. The absence of clinical findings of scleroderma and significant past medical history of radiation therapy for thyroid cancer makes radiation-induced muscle injury the most likely diagnosis. Radiographic, endoscopic, and manometric studies together confirmed the diagnosis of esophageal motor dysfunction. In the previous report, dysphagia developed years to decades after radiation. It is not surprising, therefore, that in our patient symptoms began 30 years later. Histologic changes in the esophagus may include parakeratosis, submucosal fibrosis, telangiectasia with hyalinized vessel walls, and stromal collagenization. Our report indicates the need, in the proper setting, to consider radiation-induced esophageal motor dysfunction as a cause of dysphagia that may occur with a long latency of several decades after radiation therapy.