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Diculty Swallowing After Open Heart Surgery
79
References
1. Monish R, Maheshawari A, Joshi R, etal. Vocal cord paralysis after cardiac surgery and inter-
ventions: a review of possible etiologies. J Cardiothorac Vasc Anesth. 2016;30(6):1661–7.
2. Clement M, Zhu W, Neshkova E, Bouin M.Jackhammer esophagus: from manometric diagno-
sis to clinical presentation. Can J Gastroenterol Hepatol. 2019;2019:1–7.
3. Tolone S, Savarino E, Docimo L. Radiofrequency catheter ablation for atrial brillation
elicited "jackhammer esophagus": a new complication due to vagal nerve stimulation? J
Neurogastroenterol Motil. 2015;21(4):612–5. https://doi.org/10.5056/jnm15034.
4. García-Lledó J, Clemente-Sánchez A, Merino-Rodríguez B, etal. Hypercontractile “jackham-
mer esophagus”. Rev Esp Enferm Dig. 2015;107:234.
5. Schlottmann F, Patti M.Primary esophageal motility disorders: beyond achalasia. Int J Mol
Sci. 2017;18(7):1399.
6. Jia Y, Arenas J, Hejazi RA, Elhana S, Saadi M, McCallum RW.Frequency of jackhammer
esophagus as the extreme phenotypes of esophageal hypercontractility based on the new
Chicago classication. J Clin Gastroenterol. 2016;50(8):615–8.
7. Marjoux S, Brochard C, Roman S, et al. Botulinum toxin injection for hypercontractile or
spastic esophageal motility disorders: may high-resolution manometry help to select cases? Dis
Esophagus. 2015;28(8):735–41.
8. Estremera-Arévalo F, Albéniz E, Rullán M, Areste I, Iglesias R, Vila J.Efcacy of peroral
endoscopic myotomy compared with other invasive treatment options for the different esopha-
geal motor disorders. Rev Esp Enferm Dig. 2017;109(8):578–86.
Unexpected Dysphagia andHeartburn
After Neck Radiotherapy
SubhanAhmad
1 Case Presentation
A 61-year-old female with a history of anal canal squamous cell carcinoma status
post-chemoradiation, and progressive metastatic disease involving the cervical,
supraclavicular, and mediastinal lymph nodes, pulmonary nodules, and tracheal
mass requiring radiation therapy for neck adenopathy presented to the gastroenterology clinic for evaluation of dysphagia. She described food sticking at the
level of the lower neck without associated weight loss, heartburn, odynophagia, or
chest pain. A modied barium swallow study showed delayed passage of the barium cookie at the level of the vallecula. A barium esophagram showed a hiatal
hernia and a large amount of induced gastroesophageal reux.
Esophagogastroduodenoscopy (EGD) showed a 2cm sliding hiatal hernia, lax
lower esophageal sphincter (LES), and circumferential erosive esophagitis in the
proximal 3cm of the esophagus consistent with radiation esophagitis (Fig.1). The
dysphagia was thought to be multifactorial and likely an oropharyngeal dysphagia, suspected gastroesphageal reux disease (GERD), and radiation esophagitis
in the proximal esophagus. She was instructed to take omeprazole 40mg every
morning and follow dysphagia precautions.
The patient returned to the clinic nearly twoyears later for evaluation of heartburn and ongoing dysphagia to solids and liquids. She endorsed symptoms of daily
heartburn despite taking 40mg of omeprazole twice daily and ranitidine 150mg at
bedtime. She described the dysphagia as a sensation of food getting stuck in her
chest one to two times per week, usually when eating meat. She also reported
coughing, choking, and occasional nausea with emesis, for which she occasionally
S. Ahmad (*)
Division of Hospital Medicine, Case Western Reserve University School of Medicine,
MetroHealth Medical Center, Cleveland, OH, USA
e-mail: sahmad1@metrohealth.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
R. Fass et al. (eds.), Esophageal Disorders,
https://doi.org/10.1007/978-3-031-56441-3_21
81
82
Fig. 1 Upper endoscopy showing normal z-line (left) but circumferential erosive esophagitis in
the proximal 3cm of the esophagus (right)
Fig. 2 Upper endoscopy
showing whitish
esophageal plaques and no
luminal narrowing
S. Ahmad
takes xyloxadryl oral solution but did not have odynophagia. Repeat EGD showed
a 4cm hiatal hernia, whitish esophageal plaques, and decreased esophageal peristaltic activity without any luminal narrowing (Fig.2). Biopsies did not show evidence
of eosinophilic esophagitis but did identify candida esophagitis, which was treated
with uconazole. As symptoms persisted, high-resolution esophageal manometry
(HREM) was performed and showed normal median integrated relaxation pressure
(IRP), borderline LES resting pressure, 50% weak swallows, and 50% failed swallows (Fig.3). She was diagnosed with ineffective esophageal motility (IEM), and
management of GERD was optimized with high-dose PPI and lifestyle changes as
well as dysphagia precautions. She did well and regained her lost weight.
Unexpected Dysphagia andHeartburn After Neck Radiotherapy
Fig. 3 High-resolution esophageal manometry showing a representative weak swallow. Tabular
numbers pertain to this particular swallow
83
2 Discussion
Our patient had several potential etiologies of dysphagia. As suggested by the modied barium swallow, oropharyngeal defecits were present. Radiation esophagitis in
the upper esophagus may have contributed as well. However, the clear symptom of
esophageal dysphagia with the patient experiencing food sticking at the level of the
chest suggested a problem in the more distal esophagus was the cause of the patient’s
symptoms. An investigation including upper endoscopy and HREM determined that
the likely etiology of the patient’s dysphagia was ineffective esophageal motility
(IEM). IEM is an abnormality in peristaltic amplitude, contraction vigor, and/or
peristaltic integrity with normal lower esophageal sphincter relaxation [1].
According to the Chicago Classication v4.0, at least 50% of swallows must be followed by failed contractions or more than 70% of swallows followed by ineffective
contractions to meet diagnostic criteria [2].
IEM, the most common disorder identied on HREM, is found in 15–30% of
patients undergoing the procedure, though the prevalence has lowered under the
more stringent diagnostic criteria of Chicago Classication v4.0 [2]. Patients with
IEM typically present with reux-like symptoms or dysphagia. IEM is commonly
discovered in patients with GERD, although which came rst remains unknown
[2–4]. Our patient had a large hiatal hernia and experienced heartburn that did not
respond to standard dose PPI, making the link between GERD and IEM especially
relevant to our patient. Had our patient experienced GERD symptoms that persisted
84
S. Ahmad
despite high dose PPI, reux testing to determine candidacy for more aggressive
antireux therapy, including antireux surgery, would have been appropriate.
Development of IEM after radiation therapy to the chest has not been previously
described, and in our case it remains unknown whether radiation therapy triggered
the development of IEM or the patient already had it.
The clinical signicance of IEM is primarily that it may affect GERD treatment,
specically, patient’s candidacy for endoscopic or surgical treatment of GERD.If
our patient had been diagnosed with refractory GERD, the diagnosis of IEM would
support pursuing a partial fundoplication, rather than a complete one, if antireux
surgery was to be pursued. However, IEM remains relevant on its own and can also
be a cause of dysphagia even in the absence of GERD.Management of IEM is
focused on optimizing treatment of GERD [5]. There is no effective treatment that
can restore impaired smooth muscle contractility of the esophagus and thus improve
symptoms [1–5].
References
1. Gyawali CP, Sifrim D, Carlson DA, etal. Ineffective esophageal motility: Concepts, future
directions, and conclusions from the Stanford 2018 symposium. Neurogastroenterol Motil.
2019;31:e13584.
2. Yadlapati R, Kahrilas PJ, Fox MR, etal. Esophageal motility disorders on high-resolution
manometry: Chicago classication version 4.0©. Neurogastroenterol Motil. 2021;33(1):e14058.
3. Scheerens C, Tack J, Rommel N.Buspirone, a new drug for the management of patients with
ineffective esophageal motility? United Eur Gastroenterol J. 2015;3:261–5.
4. Kahrilas PJ, Bredenoord AJ, Fox M, etal. The chicago classication of esophageal motility
disorders, v3.0. Neurogastroenterol Motil. 2015;27:160–74.
5. Triadalopoulos G, Tandon A, Shetler KP, etal. Clinical and pH study characteristics in reux
patients with and without ineffective oesophageal motility (IEM). BMJ Open Gastroenterol.
2016;3:e000126.
Achalasia inaPoor Surgical Candidate
SubhanAhmad
1 Case Presentation
An 82-year-old Caucasian male with known achalasia, diagnosed approximately
7years ago, presented to the gastroenterology clinic with progressive worsening of
dysphagia and regurgitation of solid and liquid foods several times a week. He
endorsed a ten-pound weight loss in the past year and has had to sleep at an incline
with bed wedges due to regurgitation of food at night. His past medical history is
signicant for colon cancer with a partial colectomy, coronary artery disease requiring percutaneous coronary intervention, peripheral vascular disease with prior
femoral- popliteal bypass, and a transient ischemic attack. The patient was not
treated at the time of diagnosis of achalasia due to his age and comorbidities and
thus was advised to follow a soft diet. A timed barium esophagram showed a bird
beak appearance of the distal esophagus, with less than 10% change in esophageal
contrast volume between zero and ve minutes as well as a large right epiphrenic
esophageal diverticulum (Fig.1).
An esophagogastroduodenoscopy (EGD) was completed which showed a large
esophageal diverticulum, retained food in the esophagus and stomach, and resistance at the lower esophageal sphincter (LES) all consistent with the diagnosis of
achalasia (Fig.2). Due to his age and poor surgical candidacy, one hundredunits of
botulinum toxin were injected successfully, divided into four quadrants at the
LES. Subsequent high-resolution esophageal manometry (HREM) showed 100%
failed swallows and an integrated relaxation pressure (IRP) within normal range,
but the test was non-diagnostic as the catheter appeared to enter the diverticulum
rather than cross the LES (Fig. 3). The patient had a positive symptom response but
S. Ahmad (*)
Division of Hospital Medicine, Case Western Reserve University School of Medicine,
MetroHealth Medical Center, Cleveland, OH, USA
e-mail: sahmad1@metrohealth.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
R. Fass et al. (eds.), Esophageal Disorders,
https://doi.org/10.1007/978-3-031-56441-3_22
85
86
Fig. 1 Barium
esophagram showing a
large right epiphrenic
esophageal diverticulum
Fig. 2 EGD showing
retained food in the
esophagus
S. Ahmad
developed severe dysphagia again six months later. Repeat EGD with repeat
Botulinum toxin injection into the LES was again performed. This time the patient
had a near-complete response. Subsequent HREM showed a normalized IRP with
scant peristaltic activity in the distal esophagus, consistent with successfully treated
type 1 achalasia (Fig. 4).
Plans were made for further botulinum toxin injections as needed.
Achalasia inaPoor Surgical Candidate
Fig. 3 A representative swallow from high-resolution esophageal manometry showing no peristalsis but no denite pressure inversion, suggesting the catheter did not cross into the stomach.
Tabular values pertain to this particular swallow
87
Fig. 4 A representative swallow from high-resolution esophageal manometry post-botulinum
toxin injection therapy demonstrating a median IRP within the normal range, consistent with successfully treated type 1 achalasia, as well as development of peristaltic activity in the distal esophagus. Tabular values pertain to this particular swallow
88
S. Ahmad
2 Discussion
Although we have very denitive therapies for achalasia, such as pneumatic dilation, peroral endoscopic myotomy, and surgical myotomy, not all patients are candidates for these therapies. Our patient temporarily responded to a less invasive
treatment option. Noninvasive management with oral medications or local botulinum toxin (BT) injection is considered in patients who are high-risk for a denitive
interaction, like our patient [1, 2]. BT injection is the most effective, and commonly
utilized, pharmacological therapy for achalasia. Injection into the LES inhibits the
release of acetylcholine, causing smooth muscle relaxation and facilitating the passage of the food bolus into the gastric body. This is an effective short-term therapy;
however, duration of effectiveness and need for repeat injections is variable but typically lasts between three and twelvemonths [2]. In some patients, the effect of BT
injection may last longer. Our patient responded well in the short term, and BT
injections can be repeated as needed.
References
1. Patel DA, Lappas BM, Vaezi MF.An overview of achalasia and its subtypes. Gastroenterol
Hepatol (N Y). 2017;13(7):411–21.
2. Pasricha PJ, Rai R, Ravich WJ, Hendrix TR, Kalloo AN.Botulinum toxin for achalasia: long-
term outcome and predictors of response. Gastroenterology. 1996;110(5):1410–5.
Two Disorders Wrapped into One
SubhanAhmad
1 Case Presentation
A 58-year-old African American female presented for evaluation of dysphagia
while undergoing presurgical evaluation for a laparoscopic sleeve gastrectomy. Her
past medical history was signicant for morbid obesity, well-controlled hypertension, hyperlipidemia, compensated chronic nonischemic systolic heart failure (ejection fraction 35%), obstructive sleep apnea, depression, osteoarthritis, and
prediabetes. At the time of bariatric surgery evaluation, she complained of intermittent symptoms of esophageal dysphagia but had no symptoms of gastroesophageal
reux disease (GERD).
An upper endoscopy was performed and was unremarkable. She underwent
high-resolution esophageal manometry (HREM), which showed an elevated median
integrated relaxation pressure (IRP) in both supine and upright positions, abnormally high lower esophageal sphincter (LES) resting pressure, 60% normal swallows, and 40% hypercontractile swallows (Fig.1). The patient was diagnosed with
esophagogastric junction outow obstruction (EGJOO) with hypercontractile
esophagus. Given her symptoms were intermittent and relatively mild, no changes
in her therapy were recommended, and she proceeded with bariatric surgery.
S. Ahmad (*)
Division of Hospital Medicine, Case Western Reserve University School of Medicine,
MetroHealth Medical Center, Cleveland, OH, USA
e-mail: sahmad1@metrohealth.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
R. Fass et al. (eds.), Esophageal Disorders,
https://doi.org/10.1007/978-3-031-56441-3_23
89