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Dysphagia is uncommon; however, it is considered a warning symptom, especially in the elderly population, and should prompt consideration of a neoplasm of the oesophagus. Dysphagia aortica is rare and often not considered in clinical practice. It is caused by any abnormality of the aorta that results in dysphagia. These include thoracic aortic aneurysm, aortic dissection and even a tortuous aorta. Our case is of an elderly woman, in her early 70s, with a history of treated colorectal carcinoma and hypertension, who presented with progressive dysphagia to solid foods, which, on investigations, showed a tortuous aorta causing compressions of the oesophagus at multiple levels. She was managed with dietary adjustment and optimal control of blood pressure.
Dysphagia is uncommon; however, it is considered a warning symptom, especially in the elderly population, and should prompt consideration of a neoplasm of the oesophagus. Dysphagia aortica is a rare condition, largely affecting the elderly population, and is often associated with thoracic aorta aneurysm or dissecting aorta, two conditions that are associated with high mortality with or without intervention. Our case highlights the fact that dysphagia aortica can also be due to a tortuous thoracic aorta, thus not requiring surgical intervention, as it can be managed with dietary adjustments and optimal control of blood pressure.
A woman in her early 70s was referred for evaluation of a 2-month history of dysphagia. She also reported some weight loss. She had a history of hypertension, chronic hepatitis B and colorectal cancer, which was resected followed by adjuvant chemotherapy in 2009. Her dysphagia had been progressive with intermittent worsening, and was only to solid food. The dysphagia was located mainly in the mid and lower chest. By the time she was seen in our clinic, she had already adjusted her diet to semi-solids, which had helped to ease her dysphagia.
She did not report any history of gastro-oesophageal reflux disorder and denied any associated heartburn or back pain with this current illness. She had been followed up in the general clinic and the National Cancer Centre. Her last appointment with the National Cancer Centre was several months before her symptom started, and a routine surveillance CT scan performed at that time showed no evidence of colorectal cancer recurrence. Colonoscopy carried out then did not show evidence of recurrence either.
Complete physical examination was unremarkable apart from an in situ porta-cath and an ejection systolic murmur without radiation to the carotids. There was no lymphadenopathy or abnormal peripheral pulses, and chest, cardiovascular and abdominal examinations were normal.
Upper gastrointestinal endoscopy showed prominent impressions with lumen compromised in the mid and lower oesophagus, at the levels of the aortic arch and lower half of the thoracic descending aorta. Despite full insufflation during endoscopy, the impression at the arch persisted. A barium swallow (figure 1) showed compressions of the oesophagus at several levels, including at the arch of the aorta and where the descending aorta crosses over the oesophagus. The findings were consistent with dysphagia aortica. There were no abnormal contractions and no contrast reflux was noted.
Blood investigation showed mild anaemia (haemoglobin 10.1 g/dL; normal range 10.9–14.3) with mildly elevated mean corpuscular volume (95.7 fL, normal range 75.5–95.3) with mild leucopenia (3.6×109/L; normal 3.8–11.8), normal platelets count (187×109/L; normal 150–450), mild chronic kidney injury with serum creatinine of 119.2 μmol/L (normal 50.4–98.1) and urea of 8.5 mmol/L (normal 3.5–7.2). Thyroid profile was normal.
A repeat CT scan did not show any mediastinal lymphadenopathies, aneurysm or dissection of the aorta, but showed the aorta taking a left para midline route resulting in prominent impressions seen on barium swallow. There was no aneurysm or dissection.
When the patient re-presented several months later with worsening of her dysphagia, a repeat barium swallow was performed. In addition to barium contrast, a bolus food swallow (a piece of bread soaked in contrast) was given and this demonstrated the food bolus being held up at the stricture at the level of the arch of the aorta with precipitation of the dysphagia. The food bolus passed after several swallows with relief of symptom. Again, there were no abnormal contractions and no contrast reflux was noted.
An upper gastrointestinal endoscopy excluded a diagnosis of oesophageal neoplasm, an important consideration in elderly patients presenting with dysphagia.
Barium swallow studies showed several levels of compression of the oesophagus, most marked at the level of the aortic arch.
Although not the optimal test, two barium swallow studies did not show any features of motility disorder. A manometry study, not available in our centre, would have been preferred.
A CT of the thorax excluded any mediastinal or pulmonary causes of oesophageal compression.
The patient was managed with a soft diet and optimal control of blood pressure (nifedipine modified release 90 mg daily, bendrofluazide 2.5 mg daily, doxazosin 4 mg nocte and candesartan 12 mg daily), and she has remained well without worsening of her dysphagia. She was also given intermittent courses of oral prokinetic (domperidone 10 mg three times a day).
The patient's symptoms improved significantly but she continued to have intermittent transient dysphagia, especially when taking large boluses of solid food.
In clinical practice, dysphagia is an uncommon symptom compared with other gastrointestinal symptoms in the elderly population; however, when dysphagia occurs, a neoplasm of the oesophagus needs to be considered. Other common causes of dysphagia in the elderly are motility disorder or gastro-oesophageal reflux.
Dysphagia aortica is a rare condition caused by extrinsic compressions of the oesophagus by the aorta; it can be ectatic, an aneurysm (true or pseudo), or a dissecting or even tortuous aorta.1 2 Aortic dissection and aneurysm are serious causes of dysphagia aortica.2 Another less common vascular cause of dysphagia is dysphagia lusoria, which is due to abnormal subclavian take off resulting in a vascular ring around the oesophagus, typically at the proximal third.3 Dysphagia aortica is more common among the elderly, women, those of short statue, and among patients with hypertension or kyphosis.2
Patients with dysphagia aortica usually present with dysphagia to solids but not to liquids, unless the lumen is severely compromised. Dysphagia to liquids is more in keeping with dysmotility ailments. However, as the compression progresses, dysphagia to liquids will follow. Other manifestations secondary to the effect of aortic pathology (ie, aneurysm) such as compression on the phrenic nerve causing diaphragmatic paralysis and gastrointestinal bleeding from an aorto-oesophageal fistula, have also been reported.4 5
Management includes treating the underlying causes. However, underlying causes of such dissecting aortas or aneurysms are associated with the risk of catastrophic events, and treatment options are often also high risk. Management of the underlying pathologies includes surgical repairs, which will relieve the dysphagia or intravascular stenting but will not relieve the dysphagia. Fortunately, in our patient, the dysphagia was due to a tortuous thoracic aorta, which was managed conservatively with diet modification in the form of a soft diet with control of blood pressure. However, in the earlier follow-up after diagnosis of aortica dysphagia, our patient had intermittent worsening of dysphagia, most likely due to self-limiting food bolus impactions. This was clearly demonstrated in her second barium study, when she was also given contrast soaked bread, which brought up her dysphagia when the solid bolus was held up in the aortic arch compression. Since then, the patient largely kept to a soft diet and took adequate fluid with each meal; this has led to marked reduction in her dysphagia.
In conclusion, our case highlights the need to consider dysphagia aortica in elderly patient with a history of hypertension, presenting with dysphagia. Dysphagia aortica has often been associated with significant pathology such as dissection or aneurysm of the aorta. A tortuous thoracic aorta can also cause dysphagia aortica.
Contributors: SRAH wrote the first draft and approved the final draft. IB was involved in the care of the patient, provided radiological imaging and legend, and approved the final draft. VHC looked after the patient, conceived the idea of the case report, and co-wrote and approved the final draft.
Competing interests: None declared.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.