# Clinical Cases: Esophageal Disease

## Case 1: Esophageal Adenocarcinoma

### Patient Demographics
- **Age:** 62 years
- **Sex:** Male
- **Occupation:** Accountant

### Chief Complaint
"I've been having trouble swallowing solid foods for the past 2 months."

### History of Present Illness
The patient presents with progressive dysphagia that began approximately 2 months ago. Initially, he noticed difficulty swallowing large pieces of meat and bread, but now has trouble with softer foods as well. He reports unintentional weight loss of 8 kg over the past 3 months. He has a long history of gastroesophageal reflux disease (GERD) for which he has taken over-the-counter antacids for 20 years. He admits to poor compliance with PPI therapy. He denies odynophagia, hematemesis, or melena.

### Past Medical History
- GERD (20+ years)
- Barrett's esophagus (diagnosed on EGD 5 years ago, lost to follow-up)
- Obesity (BMI 32)
- Hyperlipidemia
- Type 2 diabetes

### Medications
- Metformin 1000 mg BID
- Atorvastatin 40 mg daily
- Occasional OTC antacids

### Social History
- Former smoker (25 pack-years, quit 5 years ago)
- Social alcohol (2-3 drinks weekly)

### Physical Examination
- **Vitals:** BP 138/84 mmHg, HR 78 bpm, Weight 88 kg (down from 96 kg)
- **General:** Slightly cachectic-appearing male
- **Neck:** No cervical lymphadenopathy
- **Abdomen:** Soft, non-tender, no hepatomegaly
- **Nutritional status:** Moderate malnutrition

### Diagnostic Workup

**Upper Endoscopy (EGD):**
- Partially obstructing, ulcerated mass in the distal esophagus
- Located 35-40 cm from incisors (GE junction)
- Barrett's mucosa proximal to mass
- Scope unable to pass; tumor dilated for staging EUS

**Biopsy Results:**
- Invasive adenocarcinoma, moderately differentiated
- Arising in background of Barrett's esophagus with high-grade dysplasia

**Endoscopic Ultrasound (EUS):**
- Mass involves muscularis propria (T3)
- Several paraesophageal lymph nodes suspicious for metastasis
- No celiac axis involvement

**CT Chest/Abdomen/Pelvis:**
- Thickening of distal esophagus/GE junction
- Several periesophageal lymph nodes
- No distant metastases
- No liver lesions

**PET-CT:**
- FDG-avid mass at GE junction (SUV 12.4)
- FDG-avid periesophageal and lesser curvature lymph nodes
- No distant metastatic disease

**Staging Laparoscopy:**
- No peritoneal carcinomatosis
- No liver metastases
- Peritoneal washings negative for malignancy

### Clinical Stage
cT3N1M0 (Stage III)

### Multidisciplinary Tumor Board
- Locally advanced esophageal adenocarcinoma
- Candidate for curative intent treatment
- Neoadjuvant chemoradiation (CROSS regimen) followed by surgery

### Neoadjuvant Therapy
- CROSS protocol: Carboplatin/paclitaxel weekly x 5 with concurrent radiation (41.4 Gy)
- Completed without significant complications
- Post-treatment PET: Marked decrease in FDG avidity (metabolic response)

### Nutritional Optimization
- Dietary counseling
- High-protein supplements
- Weight stabilized during treatment

### Operative Procedure
Ivor Lewis esophagectomy performed 6 weeks after chemoradiation:
- Laparoscopic gastric mobilization and creation of gastric conduit
- Right thoracotomy with en bloc esophagectomy
- Two-field lymphadenectomy
- Intrathoracic esophagogastric anastomosis
- Feeding jejunostomy placed

### Pathology Results
- Residual adenocarcinoma, 1.2 cm
- Negative margins (R0 resection)
- Treatment effect: 40% viable tumor
- 1/18 lymph nodes positive
- ypT2N1M0 (pathologic Stage IIIA)

### Postoperative Course
- ICU x 2 days
- NGT removed POD 5
- Swallow study POD 7: No anastomotic leak
- Diet advanced slowly
- J-tube feeds supplemented
- Discharged POD 10

### Adjuvant Therapy
- Nivolumab (adjuvant immunotherapy) given residual disease and positive node

### Follow-up
- Quarterly surveillance imaging for 2 years
- EGD at 6 months: Anastomosis intact, no recurrence
- Nutritional counseling ongoing

### Teaching Points
1. Barrett's esophagus is the precursor to esophageal adenocarcinoma
2. GERD surveillance with regular EGD important for Barrett's patients
3. Dysphagia and weight loss are alarm symptoms requiring urgent evaluation
4. Multimodality treatment (neoadjuvant chemoradiation + surgery) is standard for locally advanced disease
5. Complete staging essential before treatment planning
6. Nutrition support critical throughout treatment

### Clinical Image
![Esophageal Cancer Endoscopy](case_01_image.jpg)

**Image Description:** Endoscopic image demonstrating an ulcerated, partially obstructing mass at the gastroesophageal junction consistent with esophageal adenocarcinoma. The irregular, friable mucosa with raised borders is characteristic of malignancy.

**Attribution:** Image from Wikimedia Commons, Category:Endoscopic images of esophageal cancer. Source: https://commons.wikimedia.org/wiki/Category:Endoscopic_images_of_esophageal_cancer

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## Case 2: Achalasia

### Patient Demographics
- **Age:** 38 years
- **Sex:** Female
- **Occupation:** Veterinarian

### Chief Complaint
"I have difficulty swallowing both solids and liquids, and food gets stuck in my chest."

### History of Present Illness
The patient reports a 2-year history of progressive dysphagia affecting both solids and liquids equally. She describes a sensation of food "sticking" in her lower chest. She has learned to eat slowly and drink water to help food go down. She frequently regurgitates undigested food, especially when lying down at night. She has lost 5 kg over the past year. She denies heartburn (in fact, notes decreased reflux symptoms over time). She occasionally has chest pain, particularly with eating.

### Past Medical History
- Mild GERD symptoms years ago (now resolved)
- Otherwise healthy

### Medications
- None

### Physical Examination
- **Vitals:** Normal
- **General:** Thin female, appears well
- **Neck/Chest:** No abnormalities
- **Abdomen:** Soft, non-tender

### Diagnostic Workup

**Barium Swallow:**
- Dilated esophagus with "bird's beak" narrowing at the GE junction
- Delayed esophageal emptying
- No hiatal hernia

**Upper Endoscopy:**
- Dilated esophagus with retained food debris
- Tight lower esophageal sphincter requiring gentle pressure to traverse
- Normal-appearing gastric mucosa
- Biopsies: Negative for malignancy or eosinophilic esophagitis

**High-Resolution Esophageal Manometry:**
- Absent peristalsis in esophageal body (100% failed swallows)
- Elevated integrated relaxation pressure (IRP) of 22 mmHg (normal <15)
- Elevated LES resting pressure
- Findings consistent with Type II achalasia (panesophageal pressurization)

**Timed Barium Esophagram:**
- 1-minute column height: 8 cm
- 5-minute column height: 6 cm (impaired emptying)

### Diagnosis
Type II Achalasia (Chicago Classification v4.0)

### Treatment Options Discussed
1. **Pneumatic dilation:** Effective but may require repeat procedures; perforation risk 1-3%
2. **Heller myotomy + partial fundoplication:** Durable results, 90% success rate
3. **POEM (peroral endoscopic myotomy):** Minimally invasive, excellent short-term results; higher GERD rate
4. **Botulinum toxin injection:** Temporary, reserved for poor surgical candidates

Given her age, Type II disease (best response to intervention), and desire for durable results, patient chose laparoscopic Heller myotomy with Dor fundoplication.

### Operative Procedure
- Laparoscopic Heller myotomy
- Myotomy extended 6 cm on esophagus and 2.5 cm onto stomach
- Anterior (Dor) fundoplication to prevent reflux
- Intraoperative endoscopy confirmed complete myotomy and no mucosal injury

### Postoperative Course
- Swallow study POD 1: No leak, improved passage
- Clear liquid diet started POD 1
- Diet advanced slowly over 2 weeks
- Discharged POD 2

### Follow-up
- 2 weeks: Tolerating soft diet, no dysphagia
- 3 months: Eating normal diet, gained 3 kg
- Timed barium esophagram: Marked improvement in esophageal emptying
- 1 year: Minimal reflux symptoms controlled with occasional antacids, excellent quality of life

### Teaching Points
1. Achalasia: Absent peristalsis + impaired LES relaxation
2. Dysphagia to both solids AND liquids suggests motility disorder
3. Barium swallow shows "bird's beak" appearance
4. High-resolution manometry is gold standard for diagnosis
5. Treatment aims to reduce LES pressure (myotomy or dilation)
6. Partial fundoplication prevents post-myotomy reflux
7. Long-term surveillance important (slightly increased esophageal cancer risk)

### Clinical Image
![Achalasia Barium Swallow](case_02_image.jpg)

**Image Description:** Barium swallow demonstrating the classic "bird's beak" appearance of achalasia. The dilated esophageal body tapers smoothly to a narrow point at the gastroesophageal junction due to the non-relaxing lower esophageal sphincter.

**Attribution:** Image from Wikimedia Commons, Category:Esophageal cancer. Source: https://commons.wikimedia.org/wiki/Category:Esophageal_cancer

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## Case 3: Paraesophageal Hernia

### Patient Demographics
- **Age:** 71 years
- **Sex:** Female
- **Occupation:** Retired librarian

### Chief Complaint
"I get short of breath after eating and sometimes feel like my heart is racing."

### History of Present Illness
The patient presents with a 6-month history of postprandial dyspnea and early satiety. She reports feeling "full" after eating small amounts and often experiences shortness of breath when lying down after meals. She has occasional palpitations, particularly after large meals. She admits to mild dysphagia to solids and episodic substernal chest discomfort. She has had one episode of acute severe chest pain 2 months ago that brought her to the ED, where cardiac workup was negative. She was found to have a large hiatal hernia on chest X-ray during that visit.

### Past Medical History
- Type 2 diabetes
- Hypertension
- Osteoarthritis
- History of sliding hiatal hernia (diagnosed 10 years ago)
- Prior cardiac workup negative

### Medications
- Metformin 500 mg BID
- Lisinopril 20 mg daily
- Omeprazole 20 mg daily
- Acetaminophen as needed

### Physical Examination
- **Vitals:** BP 148/82 mmHg, HR 78 bpm, SpO2 96% on room air
- **General:** Elderly female, mildly overweight
- **Chest:** Bowel sounds auscultated in left lower chest
- **Cardiovascular:** Regular rhythm, no murmurs
- **Abdomen:** Soft, non-distended

### Diagnostic Workup

**Chest X-ray:**
- Large retrocardiac air-fluid level
- Gastric bubble visible in the chest

**CT Chest/Abdomen:**
- Large Type III (mixed) paraesophageal hernia
- Majority of stomach herniated into the chest
- Organoaxial rotation of the stomach
- No evidence of volvulus or ischemia currently
- GE junction above diaphragm

**Upper Endoscopy:**
- Large hiatal hernia with stomach in chest
- GE junction located at 35 cm (above diaphragm)
- Cameron erosions (linear ulcers at diaphragmatic hiatus)
- No stricture or malignancy

**Barium Swallow:**
- Large paraesophageal hernia with most of stomach intrathoracic
- No obstruction
- Delayed gastric emptying

### Diagnosis
Type III (mixed) paraesophageal hernia with Cameron erosions

### Surgical Indication
- Symptomatic large paraesophageal hernia
- Risk of acute incarceration/volvulus
- Cameron erosions causing chronic anemia (hemoglobin 10.8 g/dL)

### Preoperative Optimization
- Cardiac clearance obtained
- Hemoglobin optimized with iron supplementation
- Nutritional counseling
- Risks discussed: 30-day mortality ~1% in elderly, recurrence risk

### Operative Procedure
Laparoscopic paraesophageal hernia repair:
- Hernia sac dissected and reduced
- Stomach reduced to abdomen
- Crural repair with primary sutures (posterior cruroplasty)
- Bio-absorbable mesh reinforcement of crural repair
- Nissen fundoplication (360-degree wrap)
- Gastropexy to prevent recurrence

### Postoperative Course
- Swallow study POD 1: No leak, wrap intact
- Clear liquid diet, advanced over 2 weeks
- Discharged POD 2
- Dysphagia expected initially (edema); resolved by 4 weeks

### Follow-up
- 2 weeks: Tolerating soft diet, no dyspnea
- 6 weeks: Regular diet, no reflux symptoms, off PPI
- 3 months: Hemoglobin improved to 12.4 g/dL (Cameron erosions healed)
- 1 year: Chest X-ray normal, patient asymptomatic

### Teaching Points
1. Paraesophageal hernias: stomach herniates alongside (not through) GE junction
2. Can cause cardiopulmonary symptoms due to mediastinal compression
3. Risk of gastric volvulus, incarceration, strangulation (surgical emergency)
4. Cameron erosions cause chronic GI blood loss and anemia
5. Surgical repair recommended for symptomatic or large paraesophageal hernias
6. Laparoscopic repair preferred with fundoplication and crural reinforcement
7. Recurrence rate significant (10-30%), higher in elderly

### Clinical Image
![Paraesophageal Hernia CT](case_03_image.jpg)

**Image Description:** CT scan of the chest demonstrating a large paraesophageal hernia with the majority of the stomach herniated into the thoracic cavity. The intrathoracic stomach is seen as a large soft tissue mass with air-fluid level posterior to the heart.

**Attribution:** Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Hiatal_hernia