1. Dysphagia Student Name: Jack Li Period: 3 Date: 7/22/09

2. History CC: “difficulty swallowing” HPI: 85 yo ♂ c/o dysphagia (solids > liquids) x 6-7mos, wt loss 5 lbs past wk / 20lbs past 1.5 yrs, “spits up” food and saliva, feels food “stuck” in chest, Ø heartburn/N/V PMH: newly dx RCC (07/2009), HTN, HLD, chronic renal insufficiency, BPH FHx: pancreatic CA (mother), breast CA (sister) SHx: prior smoker 25+ pack-yrs, social EtOH, Ø IVDU Meds: omeprazole, simvastatin, lisinopril, atenolol, ASA Allergies: terazosin

3. Physical Exam and Labs Physical exam: –Vitals: T 98.1 P 54 R 20 BP 203/91 –Abdomen: soft, non-tender, non-distended –No other significant findings Labs: –WBC: 7.0 –Hgb: 13.3 –Plts: 207 –Na 138, K 4.3, Cl 102, bicarb 29, BUN 15, Cr 1.4 Gluc 116 –Ca: 9.1 –protein 6.5, albumin 3.7 –AST/ALT/alk. phos: 18/18/51 –PTT 25.1, INR 1.0

4. Findings Barium swallow study: double contrast, biphasic exam No abnormal swallowing function Ulcerating mass at esophagogastric junction Moderate stricture 1 cm in width, 4 cm in length Delayed passage of contrast Minimal dilatation of proximal adjacent esophagus No extravasation of contrast

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8. Differential Diagnosis High –Adenocarcinoma –Squamous cell carcinoma –Asymmetric scarring –Barrett’s esophagus Low –Schatzki’s ring –Reflux esophagitis (scarring/strictures) –Achalasia

9. Diagnosis Adenocarcinoma

10. Epidemiology: – 5.69 / 100K in white males – 0.74 / 100K in white females – risk: smokers, high BMI, GERD, diet Not associated with alcohol Uncertain familial factors Endoscopy - fungating mass in distal esophagusHistology – poorly differentiated carcinoma lamina propia with infiltration into squamous epithelium

11. Barium Esophagogram Evaluation of swallowing function Morphologic abnormalities of the pharynx/esophagus Detection of esophageal carcinoma Advantages: availability non-invasive relatively inexpensive (costs $90-120) high sensitivity (95%) Disadvantages: poor ability to demonstrate fine mucosal detail cannot make dx for Barrett’s (pathologic sample needed) radiation exposure

12. Other Imaging -Esophagoscopy: visualize mucosa, obtain tissue samples -Costs $1000-$2000 -CT w/ contrast of chest, abdomen, pelvis: look for metastases -Costs: $2000-$3000 -Endoscopic USN: predicts depth of tumor invasion, extent of lymph node involvement -Costs: $13000-14000 -PET-CT: look for metastases -Costs: $4000-$5000

13. Summary -First-line imaging for dysphagia is barium esophagogram -Follow-up studies include EGD for confirmation, CT/PET for staging -Treatment decisions based on TMN staging Questions?

14. References Enzinger PC, Mayer RJ. Esophageal Cancer. N Engl J Med. 2003 Dec 4;349(23):2241-52. Epidemiology, pathobiology, and clinical manifestations of esophageal cancer. UptoDate 2009. Harewood GC, Wiersema MJ. A cost analysis of endoscopic ultrasound in the evaluation of esophageal cancer. Am J Gastroenterol. 2002 Feb;97(2):452-8. Levine MS, Stephen ER, Laufer I. Barium Esophagography: A study for All Seasons. Clin Gastroenterol Hepatol. 2008;6:11-25. Radiographic images obtained from VA CPRS/Stentor Cost information from Complete Guide to Medical Tests by H. Winter Griffin, MD Case suggestion by Dr. Joshua Rubin

15. Appendix Additional Images