S4191 Dysphagia Aortica-Induced Deglutition Syncope: A Fluoroscopic Diagnosis

Introduction: Dysphagia aortica is characterized by esophageal dysphagia due to extrinsic compression of the esophagus by the thoracic aorta. Common causes include aneurysmal dilation, tortuosity or congenital vascular anomalies. A multitude of pathologic conditions like aortic dissection, aortoesophageal fistula, and thoracic aneurysm can cause this phenomenon. Deglutition syncope is a rare neurally mediated form of syncope due to swallowing induced vasovagal response leading to bradycardia, hypotension, and loss of consciousness. We describe a rare case of dysphagia aortica presenting as an uncommonly encountered syndrome associated solely with eating out at restaurants. Case Description/Methods: An 83-year-old woman presented to the emergency department from a senior living facility after having a syncopal episode with nausea and vomiting while eating at a restaurant. Witnesses confirmed no seizure activity, focal deficits, or post-ictal state. Evaluation including CBC, BMP, electrocardiogram, and CXR were normal, and she was discharged. One month later while eating at a church dinner she had another witnessed episode of nausea, emesis and loss of consciousness associated with eating. After a few minutes, she awoke without focal deficits. A 30-day heart monitor was normal. The patient was referred to gastroenterologist after history revealed 4 episodes over the past year, all while dining at restaurants. Episodes occur after 1-2 food bites, followed by nausea, vomiting, and syncope without cardiac symptoms. No episodes occurred at her living facility. Barium esophagram with tablet showed prominent aortic knob with retention of the tablet requiring additional water to clear. Computed tomography chest confirmed esophageal compression from thoracic aorta. Per patient preference, given her comorbidities and likely low diagnostic yield, endoscopy was deferred. For treatment the patient was instructed to take smaller bites and avoid large food boluses. Since initiating behavioral changes there has been no recurrence of deglutition syncope. Discussion: Elderly patients with meal-associated syncope warrant dysphagia aortica suspicion. Large food boluses compress aortic-esophageal structures pressuring vagal-aortic plexus causing vasovagal response. Barium swallow with tablet is crucial for diagnosis. Risk factors include elderly women with kyphosis and short stature. Management can range from behavioral interventions to surgery and a detailed eating history is paramount to diagnosis. Behavioral interventions can provide significant benefit with minimal risk in the correct patient.