Dysphagia lusoria: clinical aspects, manometric findings, diagnosis, and therapy

OBJECTIVE

The lusorian artery is a rare anomaly of the right subclavian artery. This artery arises from the aortic arch distal of the left subclavian artery, crossing the midline behind the esophagus. Normally this anomaly causes no symptoms. Sometimes dysphagia first appears above the age of 40 yr.

METHODS

In the period of 1992-1997, the diagnosis of an aberrant right subclavian artery was made in five patients with dysphagia who were referred to a small community hospital. A sixth patient had a right-sided aorta with an aberrant left subclavian artery.

RESULTS

Endoscopy revealed a pulsating impression in the esophagus of three patients. Four patients had coexisting esophageal abnormalities. Barium contrast examination of the esophagus showed a characteristic diagonal impression at the level of the fourth thoracic vertebra in all patients. Computed tomography and angiography confirmed the diagnosis and excluded aneurysms. Manometric investigation of the esophagus revealed nonspecific abnormalities in five patients. Drug treatment was sufficient in three patients (mean follow-up, 6.2 yr). Three patients were operated upon because of persistent dysphagia. Through a cervical approach the artery was ligated near its root and connected with the right carotid artery. Postoperatively two patients became symptom-free, the other patient still has intermittent dysphagia.

CONCLUSION

Dysphagia can be caused by a rare anomaly of the subclavian artery. The diagnosis can be overlooked at endoscopy, but barium contrast study of the esophagus will reveal the abnormality. In patients with coexisting esophageal abnormalities the finding may be incidental and specific conservative treatment may be sufficient. Manometry cannot be used to diagnose this condition or to predict surgical outcome. When the symptoms are intractable, surgical correction should be considered even if coexisting esophageal abnormalities are present.

Dysphagia lusoria: clinical aspects, manometric findings, diagnosis, and therapy

OBJECTIVE

The lusorian artery is a rare anomaly of the right subclavian artery. This artery arises from the aortic arch distal of the left subclavian artery, crossing the midline behind the esophagus. Normally this anomaly causes no symptoms. Sometimes dysphagia first appears above the age of 40 yr.

METHODS

In the period of 1992-1997, the diagnosis of an aberrant right subclavian artery was made in five patients with dysphagia who were referred to a small community hospital. A sixth patient had a right-sided aorta with an aberrant left subclavian artery.

RESULTS

Endoscopy revealed a pulsating impression in the esophagus of three patients. Four patients had coexisting esophageal abnormalities. Barium contrast examination of the esophagus showed a characteristic diagonal impression at the level of the fourth thoracic vertebra in all patients. Computed tomography and angiography confirmed the diagnosis and excluded aneurysms. Manometric investigation of the esophagus revealed nonspecific abnormalities in five patients. Drug treatment was sufficient in three patients (mean follow-up, 6.2 yr). Three patients were operated upon because of persistent dysphagia. Through a cervical approach the artery was ligated near its root and connected with the right carotid artery. Postoperatively two patients became symptom-free, the other patient still has intermittent dysphagia.

CONCLUSION

Dysphagia can be caused by a rare anomaly of the subclavian artery. The diagnosis can be overlooked at endoscopy, but barium contrast study of the esophagus will reveal the abnormality. In patients with coexisting esophageal abnormalities the finding may be incidental and specific conservative treatment may be sufficient. Manometry cannot be used to diagnose this condition or to predict surgical outcome. When the symptoms are intractable, surgical correction should be considered even if coexisting esophageal abnormalities are present.

[Free air below the diaphragm: not always an acute surgical problem]

In three patients, two males aged 66 and 67 years with among other disorders chronic obstructive pulmonary disease (COPD) and one woman aged 24 years with a history of intestinal surgery and current abdominal pain, the chest X-ray showed free air below the diaphragm. The two males had no major abdominal symptoms, but they did have pneumonia. All were treated conservatively. Of the males, one died from pneumonia, the other recovered. The woman presented recurrent symptoms and was subjected to extensive diagnostic examinations. This revealed a marked sigmoid perforation which was repaired, after which the symptoms did not recur. Pneumoperitoneum indicates rupture or perforation of a hollow viscus in up to 90%. In these cases, prompt surgical management is the therapy of choice. In at least 10% free air under the diaphragm is due to causes which do not require surgical treatment. These causes can be divided into intra-abdominal, intrathoracic, gynaecological and iatrogenic diseases. Conservative management should only be considered if followed by frequent and intensive evaluation of the patient's condition.

[Hypertension with neurologic manifestations caused by an enlarged prostate]

A 74-year-old man suffering from hypertension had transient loss of strength in his left arm and leg. His severe hypertensive spells were caused by high-pressure chronic bladder retention. The patient had benign hyperplasia of the prostate for which transvesical enucleation was performed. The blood pressure then returned to normal. The transient neurological deficits had probably been caused by the abrupt blood pressure changes. In older male patients the possibility of this reversible cause of hypertension should be kept in mind.

Colitis and lower abdominal mass by Actinomyces israelii in a patient with an IUD

Abdominal actinomycosis is a rare disorder. The diagnosis is frequently missed preoperatively. We describe a patient who had had an intrauterine contraceptive device in situ for 5 years. She presented with a painful pelvicoabdominal mass, located between the uterus and rectum, and a colitis-like disease of the distal colon. Culture of the removed IUD demonstrated Actinomyces. She was intensively treated with intravenously penicillin for six weeks. Following this conservative treatment the abdominal tumor and the colitis-like symptoms totally disappeared. During two years follow-up she is free of symptoms and no signs of recurrence of the disease have been noticed. The case described here strongly underlines that Actinomyces infection should be born in mind in the differential diagnosis of a young female with an IUD, presenting with colitis, fever and an abdominal mass. Prolonged intravenously administered penicillin is warranted before surgery should be considered.

Randomised crossover comparison of adrenal suppressive effects of dermal creams containing glucocorticosteroids

To compare the effect of multiple dose treatment with fatty cream 0.1% hydrocortisone-17-butyrate (LLFC) and fatty cream 0.1% mometasone furoate (EFC), under occlusion on adrenal function, we performed an open label, randomised, two-period crossover study, lasting 30 days, in 12 healthy, male volunteers (age 18-45 y). Morning plasma cortisol and ACTH concentrations were determined before, during, and after the treatments, and a Synacthen test was performed before and during the treatments. Both agents suppressed plasma cortisol concentrations, EFC significantly more than LLFC. ACTH concentrations were normal and were comparable between the two treatments throughout the studies, while the Synacthen tests showed normal rises in cortisol levels. Both treatments were well tolerated. We conclude that EFC has a stronger suppressive effect on plasma cortisol values than LLFC, although for short duration treatments both suppressive effects are transient.

Asymmetrical "temporal" Pick's disease?

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Determination of low cencentrations of the quaternary ammonium compound thiazinamium methylsulphate in plasma and urine

A sensitive and selective method for the quantitative determination of the quaternary ammonium antiacetylcholine-compound thiazinamium methylsulphate (Multergan) in plasma and urine is described. The procedure is based on ion pair extraction of the compound with iodide as the counter ion. This is followed by gas chromatography using an alkali flame ionization detector. The detection limit is 2 ng ml-1 with a recovery of 88-0 +/- 6-2% from plasma, 91-4 +/- 4-6% from urine. The described method can also be applied to other quaternary ammonium compounds.