Case presentation

UNIVERSITY ASSISTANT DR. IULIA RATIU

GASTROENTEROLOGY AND HEPATOLOGY DEPARTMENT
Presenting complains
► AB , 77 yo male patient, complained of following :
- a 3-week history of progressive dysphagia ( to mention that he is able to swallow all liquids, but
the ingestion of solid food leads to regurgitation and vomiting)
- occasionally severe retrosternal discomfort
- he has lost 6 kg weight and has also noticed a decreased appetite
- nausea

He also told us that he has suffered from gastro-esophageal reflux for many years.
Patient medical history
- grade II essential hypertension
- non-ST elevation myocardial infarction 6 years ago
Medication: aspirin, bisoprolol, perindopril, atorvastatin, ivabradin.

Diet: normal
Smoking: 15 cigarettes per day since the age of 27 (he stopped 15 years ago)
Alcohol: approximately 32 units of alcohol per week
Tabaco: sometimes
No any other habits
Clinical exam
- conscious and well oriented, fatigue, pale face
- the patient’s body mass index is 28
- pulse is 68 beats/min and blood pressure= 130/70 mmHg
- no evidence of lymphadenopathy
- heart sounds are normal and there is no peripheral edema, the chest is clear
- the abdomen is soft and non-tender
Blood analyses:

Full blood count: H =3.78 mil/mmc, Hb = 11.6 g/dl, Ht = 42.6 %, L = 6900/mmc,Tr =235000/mmc;
Serum biochemestry : ASAT = 38 U/l, ALAT = 27 U/l, GGTP= 88 U/l, FA=68 U/l, BT = 0.9 mg%,
serum lipase = 58 U/l, Na = 142 mmol/l, K = 3.5 mmol/l, serum urea = 90 mg%, serum
creatinine = 1.1 mg%, VSH= 18 mm/h; serum fibrinogen= 218 mg/dl; CRP= 4.72 mg/l;
Paraclinical exam
EKG : sinus rhythm, 68 bpm , negative T waves in V4-V5, DII, DD III, AVF, no other acute ischemic
features.
Chest X- ray: normal
Abdominal ultrasound : normal
Differential diagnosis
1. Malign esophageal tumors (the most important diagnosis to confirm or exclude)
- the progressive nature of his symptoms makes this most likely
2. Benign esophageal tumors (principally esophageal leiomyoma) :
- the history for benign disease is often longer but the same pattern for solids and liquids exists
3. Benign esophageal stricture
- because he accused gastroesophageal reflux
- is characterized by slowly progressive dysphagia and heartburn
4. Achalasia
- long history of regurgitation and slowly progressive dysphagia
- individuals often experience symptoms with liquids as well as solids
Have examination and initial investigations narrowed down your differential diagnosis?

No. That’s why an upper gastrointestinal endoscopy is urgently required.

The patient undergoes an upper gastrointestinal endoscopy :

- we could see evidence of columnar lined oesophagus from 32 cm, extending to the gastro-
esophageal junction

- at 35 cm, there is an exophytic, macroscopically malignant tumor arising from the esophageal wall,
which causes narrowing of the lumen (endoscopic diag: Adenocarcinoma)

- the endoscope did not pass through this

- we took multiple biopsies from the tumor and also from the mucosa above the tumor (waiting for the
results)
Risk factors for esophageal cancer:
- Barrett’s esophagus
- Achalasia
- Lye stricture
- Ethanol abuse
- Smoking
- Coeliac disease
- Plummer- Vinson syndrome
- Tylosis
There are various subtypes of esophageal cancer:

- Squamous cell cancer arises from the cells that line the upper part of the esophagus
- Adenocarcinoma arises from glandular cells that are present at the junction of the esophagus
and stomach
Staging :
We made a CT scan of the chest and abdomen that showed us :
- concentric thickening of the distal esophagus, extending on a distance of 8 cm
- lymph nodes involvement
- no solid organ metastatic disease

Treatment – multidisciplinary team

- gastroenterologist
- surgeon
-oncologist
Management:
Usually we choose the treatment by the cellular type of cancer, the general condition of the
patient, the stage of the disease and other comorbidities present.

In this case we choose to insert an esophageal metallic stent to keep the esophagus patent
because:
- adequate nutrition needs to be assured as soon as possible because our patient cannot
swallow at all solid food anymore
- the TNM in this case was T2N2M0 (tumor invades the muscularis propria and 3-6 regional
lymph nodes spread) does not make him a proper candidate for surgery
- the age of the patient and his comorbidities
Long term use of IPP !!!
Complications
- perforation
- stent malposition
- stent migration
- respiratory tract compression, chest pain
- nausea
- bleeding
- gastroesophageal reflux
- recurrence of dysphagia
- death
Prognostic
Survival rates for esophageal carcinoma overall is low : the 1-year survival is 27% and the 5-year
survival is approximately 9%.
In this case, with oncology dispensary after stenting, will be probably over 6-12 months.