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Case 1: dysphagia for liquids and solids

Case presentation

A 52-year-old man reports a 9-month history of difficulty swallowing both liquids and solids with meals and localizes the problem to upper sternum. He gets frequent episodes of coughing and choking when lying flat at night after meals. More recently, he has noticed spontaneous regurgitation of clear, foamy liquid and undigested food into his mouth, especially when bending over after dinner. He has lost over 15 lb (6.8kg) since his symptoms began. Heartburn, which had been a problem in the past, has notably improved since his dysphagia began. Additional complaints include episodes of squeezing pain lasting for several minutes to 1 hour without radiation that can occur at any time and are unrelated to physical activity or meals. Drinking cold water sometimes alleviates the pain.

Past medical history: hypertension Medications: lisinopril Social history: employed as a businessman. Moved to the USA from Bolivia 20 years ago. Smokes 20 cigarettes per day. Drinks 3–4 glasses of wine per week

Family history: no family history of cancer or swallowing disorders Physical examination: unremarkable In particular, oral cavity without mucosal abnormalities, intact dentition, with no neck masses, lymphadenopathy or goiter. No evidence of sclerodactyly or telangiectasia.

Upper endoscopy revealed a dilated esophagus with approximately 200 mL of retained, semisolid debris despite a 36-hour liquid diet (Figure 1.1a). The underlying mucosa appeared with scattered superficial erosions and mild, diffuse nodularity. Constriction of the esophagogastric junction was noted with minimal resistance to passage of the endoscope into the stomach (Figure 1.1b). Pylorus was patent and the duodenum was normal.

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