Difficulty Swallowing Solid Foods; Food ‘Getting Stuck in the Chest’
Total Page：16
File Type：pdf, Size：1020Kb
IM BOARD REVIEW MAQSOOD A. KHAN, MD BIJO K. JOHN, MD BRET A. LASHNER, MD DONALD F. KIRBY, MD Digestive Disease Institute, Digestive Disease Institute, Digestive Disease Institute, Digestive Disease Institute, Cleveland Clinic Cleveland Clinic Cleveland Clinic Cleveland Clinic Difficulty swallowing solid foods; food ‘getting stuck in the chest’ 61-year-old woman presents to her pri- rant, there are no signs of peritonitis, the liver A mary care physician because for the last and spleen are not enlarged, and no masses can 4 weeks she has had difficulty swallowing solid be palpated. She has no asterixis. Results of her food and a feeling of food “getting stuck in the complete neurologic examination are normal. chest.” She also reports having nausea, mild Her extremities are normal with no edema. Her epigastric pain, and heartburn. She denies laboratory values are shown in TABLE 1. having fevers, chills, night sweats, weight loss, vomiting, diarrhea, hematochezia, or melena. Differential diagnosis Although the differential diagnosis at this Medical history stage is broad, a few conditions that commonly For the past 20 years, she has had gastro- present like this are: esophageal reflux disease (GERD), intermit- • Esophageal cancer tently treated with a proton pump inhibitor. • Esophageal stricture She also has arthritis, hyperlipidemia, hyper- • Esophageal webs She has had tension, and asthma, and she has undergone • Esophagitis (infectious, inflammatory) GERD for right hip replacement for a hip fracture. She • Peptic ulcer disease. has no known allergies. 20 years, She lives in the Midwest region of the ■ WHICH TEST SHOULD BE ORDERED? intermittently United States and is on disability due to her Which test will you order now for this treated with arthritis. She is divorced and has three chil- dren. 1patient? a proton pump She quit smoking 3 years ago after smoking □ Endoscopy (esophagogastroduodenoscopy) inhibitor half a pack per day for 30 years. She drinks □ Serum Helicobacter pylori antibody testing socially; she has never used recreational drugs. □ Wireless pH monitoring She recalls that an uncle had cancer, but □ Barium swallow she does not know the specific type. Endoscopy would be the best test to order. Physical examination Esophageal cancer and esophageal stricture The patient’s temperature is 96.7°F (35.9°C), must be ruled out, in view of her long his- heart rate 86 per minute, blood pressure tory of GERD, gastritis, and smoking and her 150/92 mm Hg, respiratory rate 16 per min- alarming symptoms of difficulty swallowing ute, and oxygen saturation 100% on room air. and food sticking. In this situation, endoscopy She is alert and oriented to time, place, and is the first test recommended. In addition to person. Her sclera are white, her lymph nodes its diagnostic value, it offers an opportunity to are not palpable, and her heart and lungs ap- obtain tissue samples and to perform a thera- pear normal. Her abdomen is tender in the peutic intervention, if necessary.1,2 area of the stomach and in the left upper quad- H pylori antibody testing is used in the “test-and-treat approach” for H pylori infec- doi:10.3949/ccjm.77a.09144 tion, an established management strategy for 354 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • NUMBER 6 JUNE 2010 Downloaded from www.ccjm.org on October 1, 2021. For personal use only. All other uses require permission. DIFFICULTY SWALLOWING First highlight point TABLE 1 • Endoscopy is the first test in patients with The patient’s laboratory values on presentation dysphagia with alarm symptoms. T EST RESULT NORMAL RANGE ■ CASE CONTINUES: ENDOSCOPY White blood cell count 4.5 x 109/L 4–11 The patient undergoes endoscopy, which Hemoglobin 11 g/dL 12–16 shows erosive esophagitis (grade B according Platelet count 219 x 109/L 150–400 to the Los Angeles classification8), gastritis, Aspartate aminotransferase 18 U/L 7–40 and multiple smooth nodules measuring 3 to 5 mm in the body of the stomach (FIGUR1 E ). Alanine aminotransferase 25 U/L 0–45 Multiple biopsies of the nodules show atyp- Sodium 141 mmol/L 132–148 ical lymphoid infiltrates with small cleaved Potassium 4.5 mmol/L 3.5–5.0 lymphocytes that are mostly positive for CD5, CD20, and CD43 and negative for CD10 and Chloride 106 mmol/L 98–111 CD23 by flow cytometry. In addition, a stain- Bicarbonate 23 mmol/L 23–32 ing test for H pylori is positive. Blood urea nitrogen 16 mg/dL 8–25 Comment. Our patient has had GERD for the past 20 years, intermittently treated with a Creatinine 1.0 mg/dL 0.7–1.4 proton pump inhibitor. Acid suppressive ther- Glucose 90 mg/dL 65–100 apy with a proton pump inhibitor is the stan- Albumin 4.1 g/dL 3.5–5.0 dard of care of patients with erosive esopha- gitis. In standard doses, these drugs control Total protein 9.9 g/dL 6–8.4 symptoms in most cases and heal esophagitis Total bilirubin 1.0 mg/dL 0–1.5 in almost 90% of cases within 4 to 8 weeks.9 Proton pump inhibitors are also effective for maintaining healing of esophagitis and con- In view of patients who have uninvestigated dyspepsia trolling symptoms in patients who respond to her alarm and who are younger than 55 years and have an acute course of therapy for a period of 6 to no “alarm features,” ie, red flags for cancer. 12 months.10 symptoms, The alarm features commonly described are cancer and anemia, early satiety, unexplained weight loss, ■ WHAT IS THE DIAGNOSIS? esophageal bleeding, odynophagia, progressive dysphagia, unexplained vomiting, and a family history or Which is the most likely diagnosis for our stricture need prior history of gastrointestinal malignancy.3 2patient? to be ruled out Our patient’s symptoms raise the possibil- □ Fundic gland polyps ity of cancer, so that H pylori testing would not □ Gastric hyperplastic polyps be the best test to order at this point. □ Gastric adenomas Ambulatory wireless pH monitoring with □ Mucosa-associated lymphoid tissue a wireless pH capsule is useful for confirm- (MALT) lymphoma ing GERD in those with persistent symptoms (whether typical or atypical) who do not have Fundic gland polyps are small (0.1–0.8 evidence of mucosal damage on initial endos- cm), hyperemic, sessile, flat, nodular lesions copy, particularly if a trial of acid suppression that have a smooth surface. They occur exclu- has failed.4–6 sively in the gastric corpus and are composed Barium swallow is an x-ray examination of of normal gastric corpus-type epithelium ar- the esophagus with contrast. It can show both ranged in a disorderly or microcystic configu- the anatomy and the function of the esopha- ration.11 This pattern does not match our pa- gus, and it would be the initial diagnostic pro- tient’s findings. cedure of choice for patients with dysphagia Gastric hyperplastic polyps are elongated, who have no alarm symptoms.7 However, our cystic, and distorted foveolar epithelium with patient does have alarm symptoms. marked regeneration. Other histologic find- 358 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • NUMBER 6 JUNE 2010 Downloaded from www.ccjm.org on October 1, 2021. For personal use only. All other uses require permission. KHAN AND COLLEAGUES ings are stromal inflammation, edema, and smooth muscle hyperplasia.12 This does not match our patient’s findings. Adenomas can be flat or polypoid and range in size from a few millimeters to several centimeters. Endoscopically, adenomatous polyps have a velvety, lobulated appearance. Most are solitary (82% of cases), located in the antrum, and less than 2 cm in diameter.13 This does not match our patient’s findings. MALT lymphoma, the correct answer, is characterized by small cleaved lymphocytes positive for CD4, CD20, and CD43. Although CD5 positivity is not characteristic, rare cases of MALT lymphoma may be CD5-positive and may be more aggressive.14 Other common features of MALT lym- phoma are erosions, small nodules, thickening FIGUR E 1. Endoscopic view shows multiple of gastric folds—generally suggesting a benign nodules in the body of the stomach (arrow). condition—or hyperemic or even normal gas- tric mucosa.15 Our patient’s complaint of food MALT lymphoma is linked to H pylori sticking in her chest and difficulty swallowing H pylori infection is a factor in the develop- was most likely related to the erosive esopha- ment of MALT lymphoma,30 as multiple lines gitis found on endoscopy. of evidence show: • H pylori infection has been reported in ■ A TYPE OF NON-HODGKIN LYMPHOMA more than 90% of patients with MALT lymphoma.31–35 Normal gastric mucosa contains no lymphoid • H pylori antibodies have been found in H pylori has tissue.16,17 Primary gastric lymphoma, of which stored serum drawn from patients who sub- been reported MALT lymphoma is a subtype, accounts for sequently developed MALT lymphoma.35 around 5% of gastric malignancies, with an • In response to H pylori antigens, T cells in more than annual incidence rate of 0.5 per 100,000 peo- from MALT lymphoma proliferate and 90% of patients 18–20 ple. Although rare, it accounts for 60% cause an increase in tumor immunoglobu- with MALT to 70% of cases of non-Hodgkin lymphoma lin production.36 of the gastrointestinal tract and can involve • In animals experimentally infected with H lymphoma the perigastric or abdominal lymph nodes or pylori, around one-third develop lymphoid both.21–23 Although earlier studies suggested follicles and lymphoepithelial lesions in- that its incidence was increasing, recent data cluding B cells, which are similar to hu- indicate the incidence may be decreasing, man MALT lymphoma.37 thanks to active H pylori treatment.24–26 However, only a minority of patients with Two subtypes of primary gastric non-Hodg- H pylori develop lymphoma, owing to a host kin lymphoma commonly described are MALT immune response that is not well defined.