A 45 year old African American male presents to the emergency department with a chief complaint of dizziness. He states that 4 days ago, he began to have difficulty swallowing food – he was eating a breakfast consisting of eggs, bacon & grits. He noticed some difficulty swallowing his last bite, and reports “spitting up” undigested food some time later, but denies nausea & vomiting. He describes the sensation as food “sticking” in his throat. One day later, he began noticing some difficulty with liquids. The patient denies odynophagia (pain with swallowing) and claims the difficulty is at the end (esophageal phase), not the beginning (pharyngeal phase), of his swallow. He has since had decreased intake of food & drink, but has been able to take his medications. Yesterday, he left work with complaints of lightheadedness and myalgias. He recalls a similar episode 3 years ago that resolved spontaneously.
Review of systems: Complains of dry cough, dizziness, headache; Denies dysuria, abdominal pain, SOB, chest pain, hemoptysis, fever, chills, or weight loss.
Medical history: Hypertension, Chronic kidney disease stage II, Impaired glucose tolerance
Surgical history: Ruptured patellar tendon repair, unspecified orthopedic/neurovascular hand/wrist surgery
Medications: Labetalol, Nefidipine, Lisinopril, Hydrochlorothiazide; of note, Lisinopril & HCTZ were started 4 days prior to admission
Family history: Denies
Social history: Lives with his girlfriend, works as a truck driver, smokes cigarettes occasionally on weekends, and consumes around 4 beers each day on the weekend with an occasional glass of wine with meals.
Exam: The patient is a well-nourished adult black male, approximately 5’10” & 210lbs; T 98.7F, BP 116/72, P 86, R 18 (98% on room air); non-focal neurological exam; benign abdomen; no tenderness to palpation over the sternum; CVS – RRR, no murmurs/rubs/gallops, distal pulses full & equal; Respiratory – clear to ascultation bilaterally; there is no palpable goiter, thyroid nodule, or lymph node on exam of the neck, and the patient has a full range of motion. Inspection of the oropharynx reveals no abnormalities.
Significant labs: Hemoglobin – 15 (normal); BUN 36 (elevated); Creatinine 4.6 (very high); eGFR – <15 (low); WBCs – 10.2 with normal differential; Liver function tests – Normal; Lipase – 39 (normal); Urinalysis – +protein, +leukocyte esterase, 10RBC/hpf, 4WBC/hpf, hyaline casts; FeNa = 0.4%; Thyroid studies – normal
You initiate IV hydration and order a plain film radiograph of the neck and an abdominal film, shown below.
Click to enlarge.
Click to enlarge.
You order an esophagram and sign the patient out to night float.
The patient is afebrile overnight and slept well – morning labs are significant for BUN 47; Creatinine 3.7; eGFR 22; WBCs 13.8 with normal differential. Results of the esophagram are shown below.
Click to enlarge.
What is the most likely cause of this patient’s swallowing difficulty?
- A) Angioedema
- B) Stricture
- C) Cancer/neoplasm
- D) Achalasia
- E) Foreign body
- F) Eosinophilic esophagitis
Check back in 48 hours for the answer and explanation. If you would like to submit a guest post or a medical case of your own, please use the contact page.
snyder's of hanover
January 10, 2012
d
Jim
January 11, 2012
Please note that the answer has been posted (see trackback below) – if you would like to discuss anything please do so by commenting on the follow-up post so that people can continue to participate in this challenge.
Mike W.
February 2, 2014
B