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A 48-year-old male visited to the department of gastroenterology for the evaluation of dysphagia for both liquid and solid foods for 3 months. A high-resolution manometry (HRM, version 2.1, Manoscan, Sierra Scientific Instruments Inc., Los Angeles, CA) was performed. The mean integrated relaxation pressure was 27.5 mmHg and the mean intrabolus pressure was 22.6 mmHg in 10 swallows of 5 mL. According to the classification of individual swallows based on pressure topography criteria, 7 swallows were categorized into elevated intrabolus pressure (Fig. 1A), 2 swallows into hypotensive peristalsis (Fig. 1B) and the rest one swallow into spasm (Fig. 1C). What is your diagnosis by the HRM findings?
The HRM of 10 swallows is classified into functional esophagogastric junction obstruction based on the Chicago classification of distal esophageal motility disorders. In addition, at the site just proximal to the 31 cm site from the nares, a very high pressure zone up to 140 mmHg (Fig. 1A) and the cutoff of peristalses (Fig. 1B and 1C) accompanied with upward displacement of the proximal end of the distal esophageal segment pressure and loss of the pressure transitional zone between the proximal and distal esophageal segments. Esophagoscopy revealed a circumferential ulcerative mass with marked luminal narrowing at the 31 cm to the 36 cm site from the incisor and the microscopic finding of biopsy revealed poorly differentiated squamous cell carcinoma. Esophagography showed mid esophageal luminal narrowing with abnormal proximal esophageal dilatation and delayed intermittent contrast passage to the distal esophagus. In conclusion, the present HRM findings are consistent with functional esophagogastric junction obstruction and a partial mechanical obstruction of the mid esophagus.
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