Massachusetts General Hospital Boston, Massachusetts
Jacqueline N. Chu, MD, Marc S. Sherman, MD, PhD, Brenna Casey, MD, Joseph C. Yarze, MD; Massachusetts General Hospital, Boston, MA
Introduction: To describe cases of pseudoachalasia which required EUS/FNA for diagnosis
Methods: An 84-year-old man presented with rapidly progressive dysphagia to solids over a several week time frame, with an associated 10-pound weight loss. Medical history was significant for gastroesophageal reflux, interstitial lung disease, coronary artery disease and CHF. Medication included omeprazole. Physical examination revealed a thin and chronically ill-appearing male. Auscultation of the lungs revealed rales at both lung bases. Upper endoscopy 1 year previously showed a small hiatal hernia but no other abnormality. A CT scan of the chest 2 months previously showed no abnormality and the esophagus appeared normal on that study. Upon hospital admission, upper GI endoscopy was performed and it revealed smooth stenosis at the EG junction with normal-appearing mucosa (Fig 1). An empiric 12 mm TTS dilation was performed. A barium swallow showed abrupt contrast "cut–off" at the EG junction. An esophageal manometry was consistent with type II achalasia (aperistalsis with “pan-pressurization”; elevated IRP at 50.9 mmHg and elevated basal LES pressure at 63.8 mmHg) (Fig 2). A CT scan of the chest showed "new" focal segmental thickening of the distal esophagus with extension to the gastric cardia. EUS was pursued and it revealed localized wall thickening at the EG junction (12 mm) and FNA revealed poorly differentiated adenocarcinoma (Fig 3). Discussion: In approximately 2 to 5% of patients diagnosed with achalasia, the disorder is due to malignant infiltration at the esophagogastric junction, so–called "pseudoachalasia." In our patient, findings at upper GI endoscopy, barium esophagography and esophageal manometry were all consistent with idiopathic achalasia. The clinical scenario with the triad of rapid onset of dysphagia with associated weight loss in an elderly patient, spurred us to expediently pursue EUS of the EG junction, at which time the diagnosis of pseudoachalasia was confirmed.
Figure 2. Esophageal manometry revealing type II achalasia
Figure 3. EUS revealing thickening of the EGJ wall
Disclosures: Jacqueline Chu indicated no relevant financial relationships. Marc Sherman indicated no relevant financial relationships. Brenna Casey indicated no relevant financial relationships. Joseph Yarze indicated no relevant financial relationships.