Endoscopic, radiographic, and manometric findings associated with cardiovascular dysphagia

Aberrant Right Subclavian Artery Causing Dysphagia: A Case Report of Dysphagia Lusoria

Dysphagia lusoria is a rare condition, with a prevalence of less than 1%, that occurs through secondary compression of the esophagus posteriorly by an aberrant right subclavian artery. It commonly presents with dysphagia to solids. Management is usually done with dietary modification; however, more severe and intractable cases may require surgical intervention. We describe this rare vascular anomaly in a 54-year-old female presenting with mechanical dysphagia.

Distal contractile integral measurement and vascular compression in the esophagus: a problem unsolved?

BACKGROUND

Distal contractile integral (DCI) is influenced by factors other than esophageal smooth muscle contractility, such as intrabolus pressure and vascular and respiratory movements' artifacts. We aimed to determine the size of the contribution of pressures generated by vascular compression on the esophagus to the DCI measured in HRM recordings in symptomatic patients.

METHODS

HRM manometry recordings obtained from 383 subjects referred to the GI motility laboratory at a tertiary center (2012-2016) were evaluated by visual inspection for evidence of strong vascular compression (SVC) of the esophagus. Clinical, demographic, manometric, and serologic data for Chagas disease were obtained. Subjects were classified, respectively, as asymptomatics (ASYM) or symptomatics (SYMP). DCI and SVC-DCI were measured, and the SVC-DCI/DCI ratio was expressed as a percentage and the difference between DCI and SVC-DCI (neat-DCI) was calculated. DCI, SVC-DCI, SVC-DCI/DCI % and neat-DCI from SYMP and ASYM were compared.

RESULTS

SVC was conspicuous in 42 of 383 subjects (11%). In 33 subjects, SVC was detected only in supine position. SVC was localized in middle esophagus in 21 subjects (50%), in distal esophagus in 12 subjects (29%) and in both regions in 9 subjects (21%). In 9 subjects, SVC vanished from the swallowing window analysis (21%).

CONCLUSIONS

SVC is a common finding in esophageal HRM study, particularly in the supine position. Occasionally, its contribution to DCI value is sufficiently great to masquerade esophageal hypocontractility. Different manometric protocols may be required in patients with SVC.

Fully percutaneous treatment of an aberrant right subclavian artery and thoracic aortic aneurysm

Treatment of an aberrant right subclavian artery (arteria lusoria) aneurysm is traditionally performed surgically or via a hybrid approach. To our knowledge, a fully percutaneous approach has not yet been reported. We describe the fully endovascular exclusion of an aberrant right subclavian artery and thoracic aortic aneurysm. This approach has the potential advantage of avoiding complications of an open surgical repair, particularly in patients of advanced age and/or with multiple comorbidities.

Manometry and impedance characteristics of achalasia. Facts and myths

BACKGROUND

Achalasia is defined manometrically by an aperistaltic esophagus. Variations in the manometric findings occur in achalasia suggesting that all manometric features should not be required to diagnose achalasia. Combined multichannel intraluminal impedance and esophageal manometry (MII-EM) allows both a functional and a manometric evaluation of esophageal motility and identifies chronic fluid retention.

AIM

To compare manometric and MII characteristics in patients with achalasia.

METHODS

Retrospective review of 73 MII-EM tracings from patients with achalasia done in our laboratory between October 2001 and December 2004 (38 females; mean age=53.5 y). Patients with previous esophageal interventions were excluded. Manometric and MII characteristics were identified and compared during 10 liquid and 10 viscous swallows. Patients were also divided into 2 groups: vigorous achalasia (VA) and achalasia.

RESULTS

Twenty-two of the seventy-one (31%) achalasia patients had a hypertensive lower esophageal sphincter (LES). The mean lower esophageal sphincter pressure (LESP) for the 71 patients with achalasia was 37.9+/-21.2 mm Hg compared with 27.3+/-9.3 mm Hg (P<0.05) in the 73 patients with normal motility. The mean LESP in patients with achalasia was 36+/-20.3 mm Hg compared with 47+/-23.2 mm Hg (P<0.05) in patients with VA. Elevated intraesophageal pressure (IEP) was noted in 45/73 (61.6%). The mean LESP in this group was 41.1+/-22.9 mm Hg compared with 32.5+/-17 mm Hg (P<0.05) with normal IEP. The mean baseline impedance for achalasia was 801+/-732 compared with 1265.2+/-829.5 Omega (P<0.05) for the VA patients.

CONCLUSIONS

Most patients with achalasia have elevated IEP, elevated LES residual pressure, normal LES pressure, and low baseline impedance. All manometric features should not be required to diagnose achalasia. Patients with an elevated IEP are likely to have an elevated LES pressure and LES residual pressure. Low MII values identify chronic fluid retention and helps confirm the diagnosis.

Dysphagia lusoria: a comprehensive review

Dysphagia lusoria is a rare vascular anomaly identified in a small number of patients being evaluated for dysphagia. The purpose of this paper is to present an illustrative case and provide a comprehensive review of the underlying anatomy, diagnosis, and management of dysphagia lusoria based on a review of the medical and surgical literature over the past 20 years.

[Dysphagia aortica--case report]

INTRODUCTION

Dysphagia aortica is a swallowing condition caused by external compression of the esophagus due to aortic aneurysm or atherosclerotic changes affecting the aorta. The case report on this rare cause of dysphagia should contribute to better diagnosis of dysphagia aortica and swallowing difficulties in general.

CASE REPORT

A 63-year-old male patient was hospitalized duo to a four month history of intermittent swallowing difficulties. Chest radiography showed a widened mediastinum and an enlarged aortic arch. Rigid esophagus endoscopy was done in general endotracheal anesthesia. At 28 cm from the upper incisors, a difficulty in passing the endoscope appeared, revealing an external compression as a probable cause, since the whole esophagus had no intraluminal pathological changes. Contrast esophagography revealed an aortic aneurysm. The esophagus had a normal lumen width, wall tension and elasticity, and smooth contours. After cardiovascular examination and magnetic resonance imaging, a giant aneurysm of the aortic arch was diagnosed.

DISCUSSION

Patients with dysphagia aortica as well as patients with any other swallowing difficulties should be managed by multidisciplinary "dysphagia team". The team should include an otorhinolaryngologist, neurologist, radiologist, gastroenterologist, surgeon, dietitian, speech and language therapist and specially trained nurses.

CONCLUSION

Aneurysm of the thoracic aorta is a very rare cause of dysphagia. Mild to moderate symptoms can be in great disproportion with the severe condition which causes them.