Unusual cause of Dysphagia: A case report

S. Meenatchi¹, K. Arivarasan²

¹Physician Assistant, Kauvery Hospital, Trichy Cantonment

²Consultant Gastro Enterologist, Kauvery Hospital, Trichy Cantonment

Abstract

Dysphagia is defined as difficulty in swallowing. The condition results from impeded transport of liquids, solids or both from pharynx to the stomach. Dysphagia usually classified as oropharyngeal dysphagia, esophageal dysphagia, complex neuromuscular dysphagia, functional dysphagia. Acute dysphagia is usually due to food or foreign body impaction or acute stroke. We present a rare case of acute onset of dysphagia.

Case presentation

A 76- years-aged female presented with chest pain and difficulty in swallowing for 1 day. Patient was known to have Type II diabetes mellitus and Coronary artery disease – S/P PTCA to LAD, on antiplatelet therapy (6 months back).

Patient was initially evaluated at Heartcity. CAG showed patent stent slow flow and was managed conservatively. But patient had persistent chest and epigastric discomfort.

USG – abdomen showed the normal study. CECT abdomen showed soft tissue density lesion within the middle and distal esophagus, with complete luminal obstruction/sliding hiatus hernia. UGI scopy showed large submucosal hematoma seen extending from upper esophageal sphincter; the hematoma totally occluded the lumen.

Fig. 1. UGI scopy.

Fig. 2. CECT – Abdomen on the day of admission.

Fig. 3. Repeat CT abdomen.

Fig. 4. Relook UGI scopy.

Gastrograffin swallow

Patient was initially admitted in ICU, was started on fentanyl and PPI infusion, and kept nil per oral. After 2 days analgesics were tapered and stopped. Patient was started on oral clear liquids. Relook UGI scopy done on 4th day of admission revealed large sloughed off mucosa with resolved hematoma. Her hemoglobin level was regularly monitored and she was discharged with oral liquid diet after 7 days of hospitalization.

Discussion

Histologically esophagus comprises of innermost mucosal layer, submucosal layer, muscular and adventitial layer. The 2nd layer submucosa which connects mucosal and muscular layer contains blood vessels, meissner nerve plexus and esophageal glands.

Pathogenesis of intramural esophageal bleeding leading to hematoma formation and submucosal dissection is often unclear. Several causes have been proposed- emetogenic, traumatic, related to aortic disease and coagulopathic.

Conclusion

Usually intramural hematoma is a very rare and benign condition. Prognosis is usually excellent with proper diagnosis and management.

Ms. S. Meenatchi

Physician Assistant

Dr. K. Arivarasan

Consulant Gastroenterologist

Unusual cause of Dysphagia: A case report