Dysphagia: A Case of Successful Treatment in an Elderly Patient with Arteriovenous Malformation
Introduction:
A 74-year-old woman presented with complaints of heartburn after meals.
Complaints:
The patient noted that discomfort occurred approximately 2–3 times a week. It was accompanied by belching, difficulty swallowing, and unpleasant sensations in the upper abdomen.
To alleviate her symptoms, the woman took antacids, which neutralize hydrochloric acid in gastric juice.
History:
The symptoms first appeared about a year ago and remained consistent since then.
The patient also mentioned a slight hoarseness of voice and occasional coughing, which she attributed to taking Prestarium to lower blood pressure when it rose above 150 mm Hg.
The woman has been suffering from arterial hypertension for 10 years, with blood pressure peaking at 170/110 mm Hg. However, she has not undergone a complete examination. She regularly takes Aspirin Cardio.
Examination:
Upon examination, the skin appeared normal in color, moist, elastic, and resilient, without eruptions. Body mass index (BMI) was 22.8 (normal).
Clear lung percussion notes were heard. Breathing was normal, without wheezing. Respiratory rate was 18 breaths per minute. Cardiac boundaries were not enlarged, with rhythmic heart sounds. Heart rate was 70 beats per minute, without pathological murmurs. Blood pressure was 160/100 mm Hg.
Upon palpation, the abdomen was soft, with moderate tenderness in the upper part. The liver was not enlarged. Stool was regular and formed. Kidneys were not palpable, and percussion over the loin was painless. Urination was free, up to 2000 ml per day.
General and biochemical blood analysis parameters were within normal limits. Lipid profile revealed elevated cholesterol levels (above 6.3 mmol/L) and low-density lipoprotein (LDL) at the upper limit of normal (4.5 mmol/L).
Esophagogastroduodenoscopy (EGD) revealed a submucosal, firm, elastic, mobile formation of oval shape in the middle third of the esophagus, measuring 1.4 × 2.3 × 2.5 cm, protruding into the lumen by 4–6 mm. The mucous membrane above it was unchanged. The cardiac notch (transition zone from esophagus to stomach) was elastic but did not completely close.
Additionally, signs of:
- Gastroesophageal reflux disease (GERD);
- Focal atrophy with enterolysis of the mucous membrane of the vault and upper third of the stomach (appearance of intestinal-type cells);
- Moderately expressed superficial gastritis of the antral part of the stomach;
- Focal atrophy of the mucous membrane of the distal part of the duodenal bulb;
- Duodenogastric reflux (DGR) were diagnosed.
To exclude a tumorous process in the esophagus or mediastinum, the woman underwent barium swallow radiography and spiral computed tomography (CT).
X-ray on March 5 revealed circular narrowing in the middle third of the esophagus, with something pressing on the posterior wall. Additionally, ulcerated contours and widened folds of the mucous membrane were noted.
CT on March 10 did not detect pathological neoplasms in the thoracic cage or mediastinum.
Diagnosis:
GERD. Moderately expressed superficial antral gastritis, DGR. Leiomyoma of the middle third of the esophagus.
Treatment:
The patient was prescribed a proton pump inhibitor (PPI) – Rabeprazole 20 mg in the morning, 20 minutes before meals. She was also advised to follow a diet and consult with an oncologist. For further observation, she was referred to an outpatient clinic.
However, over time, the woman’s condition worsened, and she returned to the gastroenterologist complaining of hoarseness, occasional loss of voice, dry cough up to 4 times a day, difficulty swallowing solid food, and episodes of choking.
Repeat EGD revealed:
- Submucosal semicircular formation in the middle third of the esophagus protruding into the lumen by 2/3, causing narrowing.
- The spread of the formation along the length of the esophagus by 4–5 cm, with a 50% increase in size compared to the previous examination.
The Valsalva maneuver, during which the patient had to exhale while straining the abdomen, yielded a positive result, indicating problems with the function of the venous valves.
As the endoscopic findings worsened, the woman underwent endoscopic ultrasound (EUS) , which revealed:
- No varicose veins;
- The esophagus with elastic walls was freely passable, with no changes in the lumen;
- In the middle third of the esophagus (at a depth of 30 cm), there was an indentation from the outside, occupying 1/3 of the esophageal circumference, extending up to 4–5 cm, narrowing the lumen by half (when air was introduced, the lumen increased by 20–25%);
- The cardiac notch was completely closed;
- There was no reflux of gastric contents;
- The echoendoscope passed freely into the esophagus: above and below the narrowed area, the esophageal wall was uniform and five-layered without pathology; at the level of the narrowing, vascular formations measuring 8.2 × 5.6 and 11.1 × 7.6 mm were detected 8–10 mm away from the esophageal wall;
- Lymph nodes were normal.
Based on all the examinations and symptoms, the woman was diagnosed with lusoria dysphagia caused by anomalous origin of the right subclavian artery from the aorta. To definitively confirm the diagnosis, she underwent CT without intravenous contrast due to allergy to iodine-containing preparations.
CT on July 9 revealed an anomalous origin and course of an additional right subclavian artery.
Thus, the patient was diagnosed with arteriovenous malformation in the middle third of the esophagus with its narrowing. Additionally, during all previous examinations, insufficient closure of the cardiac notch, GERD, NERD (non-erosive reflux disease), exacerbation of chronic superficial gastritis, and DGR were detected.
Subsequently, the patient was prescribed continuous intake of PPIs and a soft diet. She was also advised to be monitored by a vascular surgeon and cardiologist to adjust cholesterol and LDL levels in the blood and to undergo periodic EGD to monitor submucosal formation and esophagitis.
On the background of treatment with proton pump inhibitors, the woman’s condition improved: heartburn, belching, abdominal discomfort, and other symptoms subsided. Regarding dysphagia, she is under observation by a vascular surgeon.
Conclusion:
This clinical case demonstrates that progressive in elderly patients may be caused by arteriovenous malformation of the right subclavian artery. The use of modern diagnostic methods, such as endoscopic ultrasound of the upper gastrointestinal tract and spiral CT with vascular contrast, allows for accurate and rapid diagnosis of rare vascular pathology.