Case Presentation: An 80 years old male with pertinent history of coronary artery disease, descending fusiform thoracic aortic aneurysm and systolic heart failure presented with shortness of breath and chest pain. Exam revealed bibasilar lung crackles, elevated jugular venous distension and bilateral lower extremities edema. CT Angiogram of the chest showed bilateral pulmonary embolism, known thoracic aneurysm measuring 5.2 cm, vascular congestion, and moderate bilateral pleural effusions. He was started on heparin drip for anticoagulation and diuretics for heart failure exacerbation. Vascular surgery recommended monitoring of the aneurysm with repeat imaging in one year. Echocardiogram showed worsening ejection fraction from an estimated 45% to 15%. Left atrium was significantly dilated with Left Atrium End Systolic Volume Index of 57 ml/m2 (Reference range: 22+/-6 ml/m2).
During the hospitalization, he was found to have acute on chronic dysphagia. He reported dysphagia for two months, more for solids than liquids with no odynophagia. There was no reported weight loss although it should be noted that patient had volume overload on admission. On swallow evaluation, he was able to take thin liquids and pureed solids without overt signs of aspiration but within 1-2 minutes, he had belching and a feeling of food regurgitation. A barium swallow showed moderate to marked narrowing of the distal esophagus with extrinsic displacement due to compression by an enlarged heart and calcified arteriosclerotic thoracic aorta. This condition is known as Dysphagia Aortica. Further workup with esophageal manometry and upper gastrointestinal endoscopy was considered. Unfortunately, he developed clostridium difficile colitis and hemorrhagic shock due to a large retroperitoneal hematoma, and died.
Dysphagia is a commonly encountered symptom in hospitalized patients. While most cases are due to underlying oropharyngeal, esophageal or neurologic conditions, it is important to recognize cardiac dysphagia in patients with extensive cardiovascular disease. Mechanical compression of distal esophagus by dilated left atrium or tortuous atherosclerotic aneurysmal thoracic aorta is known as dysphagia megalatriensis and dysphagia aortica respectively. An enlarged left atrium can mechanically impinge the distal esophagus leading to difficult deglutition and upstream esophageal dilatation. Our case is unique, as distal esophagus is compressed in the restricted space between enlarged left atrium anteriorly and rigid tortuous aneurysmal aorta posteriorly thus depicting manifestations of both dysphagia megalatriensis and dysphagia aortica. As these conditions are rare and not much described in literature, the incidence of cardiovascular dysphagia is unknown. It is mainly a diagnosis of exclusion. Barium esophagograms reveal posterior displacement and impingement of the distal esophagus with upstream dilatation and achalasia. Esophageal manometry and endoscopy will depict superimposed pulsations and elevated intraluminal pressures. Investigations including CT Angiography of the chest and Echocardiography will aid in confirming the diagnosis. Treatment depends on the severity of cases. Altering the dietary consistencies should be done in mild cases whereas, endovascular aneurysm repair and aggressive surgical approach is recommended in severe cases.
Conclusions: Our case highlights the need to consider dysphagia aortica and megalatriensis in elderly patients with cardiovascular conditions
To cite this abstract:Trivedi, MC; Javed, S; Saghir, A. DYSPHAGIA AORTICA WITH LEFT ATRIAL COMPRESSION: A RARE CAUSE OF DYSPHAGIA IN AN ELDERLY MAN. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 891. https://www.shmabstracts.com/abstract/dysphagia-aortica-with-left-atrial-compression-a-rare-cause-of-dysphagia-in-an-elderly-man/. Accessed May 24, 2019.