Gastroenterology clinical image challenge: An 81-year-old woman was evaluated for progressive, intermittent solid food dysphagia for eight years. She had been managed previously with a daily dose of a proton pump inhibitor with minimal response. She had no heartburn, regurgitation, nausea, emesis, food impaction, altered bowel pattern, gastrointestinal bleeding or weight loss. Her past medical history was significant for psoriasis, seasonal allergies and hypothyroidism. She reported no family history of gastrointestinal disorders. She was a former smoker with a 30 pack-year history and reported alcohol use socially.
Physical examination was notable for a woman with a normal body mass index in no acute distress. Vital signs were within normal limits. Her abdomen was soft, nontender, and nondistended on palpation without evidence of hepatosplenomegaly. Bowel sounds were normal. Pertinent negatives include a normal skin and oral examination.
Normal oropharyngeal swallowing physiology was noted for all consistencies on a modified barium swallow examination. A barium esophagogram demonstrated a limited distensibility of esophagus with impaired passage of the administered barium pill (Figure). High-resolution esophageal manometry was normal with 100% peristalsis and a normal IRP of 1.3 mm Hg. An upper endoscopy showed a severe esophageal stenosis along the entire length of the esophagus measuring approximately 10 mm in diameter with moderate resistance to passage of an adult gastroscope (Figure).
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