Dysphagia
https://doi.org/10.1007/s00455-020-10172-5
CLINICAL CONUNDRUM
An Uncommon Cause of Esophageal Dysphagia and Food Impaction
Daniel L. Cohen1 · Anton Bermont1 · Haim Shirin1
Received: 1 July 2020 / Accepted: 6 August 2020
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Case Presentation
A 68-year-old man presented to the emergency room with
symptoms of an esophageal food impaction for several
hours. The symptoms began after breakfast which included
two pieces of garlic. Careful history revealed that the patient
suffered from intermittent dysphagia to solid foods for more
than a decade. He was not able to swallow pills unless they
were crushed. He was, however, able to swallow liquids
without difficulty. He denied weight loss, heartburn, or
odynophagia. He had not sought medical attention for his
dysphagia symptoms, and had never performed an endos-
copy or esophagram for investigation. Physical examination
was normal. Laboratory studies were also normal without
anemia.
Upon urgent upper endoscopy, two pieces of garlic were
identified in the upper esophagus. They were removed with
an endoscopic basket. Afterwards, the endoscope was re-
introduced and the area of the impaction was further evalu-
ated. The mucosa in the upper esophagus between 18 and
20 cm from the incisors appeared circumferentially abnormal
with salmon-colored mucosa (Fig. 1). At 20 cm, the distal
end of the abnormal mucosa, there was a stricture (Fig. 2).
Biopsies were taken from the stricture and surrounding area
(Fig. 3). The scope was able to pass the stricture with resist-
ance. Evaluation of the remainder of the esophagus revealed
the normal grey-white squamous epithelium of the esopha-
gus with no other lesions.
* Daniel L. Cohen
docdannycohen@yahoo.com
1
The Gonczarowski Family Institute of Gastroenterology
and Liver Diseases, Shamir (Assaf Harofeh) Medical Center,
Zerifin, affiliated with the Sackler School of Medicine, Tel
Aviv University, Tel Aviv, Israel
What is the Diagnosis?
Answer
The biopsies taken during the endoscopy revealed the pres-
ence of ectopic gastric mucosa (Fig. 3) without signs of dys-
plasia or carcinoma. This confirmed the diagnosis of a peptic
stricture secondary to acid secretion from an inlet patch as
the etiology of the patient’s dysphagia and food impaction.
Discussion
Heterotopic gastric mucosa of the esophagus (also known
as an esophageal inlet patch) is a common congenital abnor-
mality occurring in up to 14% of adults in an endoscopic
series [1]. Typically these patches present as small, discrete
areas in the proximal (cervical) esophagus. Less commonly,
they may have synchronous lesions or be fully circumferen-
tial, as was noted in our patient [2].
Esophageal inlet patches are usually asymptomatic and
diagnosed incidentally during endoscopy. However, symp-
toms referable to these lesions from the local effects of acid
production, such as globus sensation, hoarseness, and throat
clearing, have been reported [2, 3]. These symptoms may
resolve after endoscopic ablation of the inlet patch [3].
Dysphagia due to an inlet patch is also a rare compli-
cation. This occurs due to acid production resulting in a
stricture. Sometimes, as the stricture heals itself through a
reparative process, an upper esophageal web remains [2].
There are less than 20 case reports of dysphagia due to an
inlet patch-related stricture or web, and in only a handful of
these cases did a food impaction occur. Stricture formation
may be more likely to occur if the inlet patch is a larger size
such as occurs with circumferential patches [4]. Dyspha-
gia symptoms may successfully be treated with endoscopic
dilatation, ablation, and/or gastric acid suppression [2, 3].
At his follow-up visit, our patient reported feeling well.
He said that he had been coping with his dysphagia symp-
toms for many years and had no desire for any treatments.
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 D. L. Cohen et al.: An Uncommon Cause of Esophageal

Specifically, he refused an endoscopic dilation and proton-

pump inhibitor medication. He did promise to be more care-
ful when chewing his food in the future. He has not returned
to our clinic since this episode.

Compliance with Ethical Standards 

Conflict of interest  None of the authors have any conflicts to report.

References
1. Peitz U, Vieth M, Evert M, Arand J, Roessner A, Malfertheiner
P (2017) The prevalence of gastric heterotopia of the proximal
esophagus is underestimated, but preneoplasia is rare—correlation
Fig. 1  An area of abnormal mucosa in the upper esophagus with Barrett’s esophagus. BMC Gastroenterol 17(1):87
2. von Rahden BHA, Stein HJ, Becker K, Liebermann-Meffert D,
Siewert JR (2004) Heterotopic gastric mucosa of the esophagus:
literature-review and proposal of a clinicopathologic classifica-
tion. Am J Gastroenterol 99(3):543–551
3. Ciocalteu A, Popa P, Ionescu M, Ionut Gheonea D (2019) Issues
and controversies in esophageal inlet patch. World J Gastroenterol
25(30):4061–4073
4. Shimamura Y, Winer S, Marcon N (2017) A giant circumferen-
tial inlet patch with acid secretion causing stricture. Clin Gastro-
enterol Hepatol 15(4):A22–A23

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Daniel L. Cohen  MD

Anton Bermont  MD

Haim Shirin  MD

Fig. 2  A stricture at the distal end of the abnormal mucosa

Fig. 3  Biopsies from the abnormal area revealed gastric mucosa

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