Gastro Curbside ConsultA Curious Case of Rapidly Progressing Dysphagia
Section snippets
Establishing the Diagnosis
FNA demonstrated tumor cells with immuno-staining positive for p40 and CK5, which are markers of squamous differentiation, as well as p16, which is typically seen in human papillomavirus–related SCC consistent with the patient’s known cervix-primary SCC. The metastatic cervical SCC was located in the tissue of the esophageal wall, establishing the diagnosis of secondary achalasia.
Review
The diagnosis of secondary achalasia should be considered in patients with rapid onset and short duration (<1 year) of symptoms, weight loss, or age ≥50 years.1, 2, 3 However, symptoms alone cannot distinguish secondary from primary achalasia, and imaging and possibly EUS must be considered if there is suspicion. Careful examination of the esophagram in this patient (Figure B) demonstrated a long narrowed distal esophageal with multifocal segments of stenosis measuring more than 10 cm over the
Patient Outcome
Given the patient’s persistent symptoms, the stenosis was stented with a covered metal stent under fluoroscopic guidance. She later developed a tracheo-esophageal fistula and had to have another covered metal stent placed owing to migration. Ultimately, she required percutaneous endoscopic gastrostomy placement. She was continued on bevacizumab and pembrolizumab with plans for outpatient chemotherapy options to treat underlying malignancy.
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Conflicts of interest The authors disclose no conflicts.