S4227 A Rare Case of Dysphagia Aortica Presenting as Pseudoachalasia

Introduction: Dysphagia aortica is a condition characterized by esophageal obstruction due to extrinsic compression by the aorta. Its symptoms and imaging studies can mimic other causes of dysphagia, including achalasia. Here we present a case in which dysphagia aortica was diagnosed using endoscopic functional lumen imaging probe and endoscopic ultrasound. Case Description/Methods: An 82-year-old woman with past medical history of kyphosis, prosthetic mitral valve, and diffuse atherosclerotic disease was referred to our institution for tertiary evaluation of chronic, progressive dysphagia with associated 60-pound weight loss. She had undergone esophagogastroduodenoscopy previously which revealed dilated esophagus with food debris throughout, but no luminal obstruction. Upon presentation, she underwent barium esophagram which showed a dilated esophagus concerning for achalasia. An esophagogastroduodenoscopy was performed which surprisingly revealed an area of external compression in the distal esophagus, just proximal to what was otherwise a widely patulous gastroesophageal junction. Endoscopic functional lumen imaging probe was performed which showed normal distensibility index and minimum diameter of the gastroesophageal junction. The area of suspected external compression showed distensibility index 1.7 mm2/mmHg and a minimum diameter of 11.6 mm. A computed tomography scan of the chest suggested esophageal compression by the aorta. Subsequent endoscopic ultrasound revealed compression of the lower third of the esophagus by the aorta, confirming the diagnosis of dysphagia aortica. Given her age and poor functional status, the patient had a percutaneous gastrostomy tube placed for enteral nutrition pending evaluation for possible vascular intervention in future. Discussion: There are few reported cases of dysphagia aortica in the literature, with some of the associated risk factors including older age, female sex, and history of kyphosis. Unlike in most cases of dysphagia aortica where patients have a clearly evident thoracic aortic aneurysm or tortuous aorta, our patient had an otherwise normal appearing aorta on computed tomography imaging. Furthermore, she was symptomatic for nearly a year without a diagnosis resulting in severe protein-calorie malnutrition, which underscores the importance of recognizing this rare etiology of dysphagia.