Dysphagia Lusoria: Using the EndoFLIP

CASE REPORT

We present a case in which Endo functional luminal imaging probe (FLIP) and chest computed tomography (CT) led to diagnosis of symptomatic dysphagia lusoria. A 48-year-old woman presented with solid food dysphagia, regurgitation, and intermittent globus sensation for 1 year. Her vital signs, physical examination, laboratory test results, abdominal ultrasound, and esophagogastroduodenoscopy were unremarkable. She was started on pantoprazole 40 mg 2 times daily, which initially improved her symptoms. Later on, she developed severe food aversion because of progressive symptoms, which led to unintentional 35 pound weight loss. She was transitioned to lansoprazole 30 mg 2 times daily.

Further workup included a barium esophagram, which showed mild esophageal dysmotility in the middle third of the esophagus. Manometry demonstrated a hypercontractile esophagus (mean distal contractile integral of 8,000). The integrated pressures, although normal on supine swallow, were elevated on upright swallows.

Esophagogastroduodenoscopy with EndoFLIP was performed to rule out obstructive pathology and confirm hypercontractile esophagus, which showed extrinsic compression in the upper third of the esophagus. FLIP topography was performed using stepwise distension using saline, infused to a volume of 50 mL, with observed distensibility of approximately 3.85 mm2/mm Hg. Repetitive antegrade and retrograde contractions were observed. Static compression was noted around the midesophagus (Figure 1). Chest CT showed an aberrant right subclavian artery compressing the esophagus (Figures 2–4).

F1Figure 1.:

FLIP topography at the middle third of the esophagus. EGD with EndoFLIP showed extrinsic compression (indicated by red arrow) in the upper third of the esophagus. Repetitive antegrade and retrograde contractions were observed. Static compression was noted around the midesophagus. EGD, esophagogastroduodenoscopy; FLIP, functional luminal imaging probe.

F2Figure 2.:

The aberrant subclavian artery signified by the red arrow arising from the descending aorta.

F3Figure 3.:

The right subclavian artery signified by the red arrow is arising from the aortic arch compressing the esophagus posteriorly.

F4Figure 4.:

Sagittal view of CT neck angiography showing the aberrant right subclavian artery indicated by the red arrow. CT, computed tomography.

She underwent hybrid repair of the aberrant right subclavian artery with right common carotid-to-subclavian artery bypass grafting with ligation of the proximal subclavian artery and stent graft repair of the descending thoracic aorta with an intentional partial coverage of the left subclavian artery. At the 4-week follow-up, she reported complete resolution of symptoms.

This is the first case reported to use EndoFLIP to assist in diagnosis of dysphagia lusoria with CT confirmation. Hundt et al (2019) reported using EndoFLIP to confirm diagnosis of achalasia.1 EndoFLIP measures luminal dimension, contractility, and pressure during controlled volumetric distension.2 It is frequently used to evaluate and detect motility problems associated with esophageal achalasia, fundoplication, and eosinophilic esophagitis.2

Our case was specifically challenging because of a lack of classical features that are usually seen on initial radiological and endoscopic images. Real-time imaging confirmed a persistently narrow luminal dimension in the midesophagus, consistent with a compression effect from an aberrant vasculature. With the advent of EndoFLIP, we demonstrate another possible utility of this device for the gastroenterologist in reducing the delay in diagnosis of this often morbid disease.

DISCLOSURES

Author contributions: E. Becker wrote the manuscript. O. Siddique and J. Neslter revised the manuscript for intellectual content. E. Becker, O. Siddique, and J. Nestler approved the final manuscript. O. Siddique is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

REFERENCES 1. Hundt M, Sharma P, Pourmorady J, et al. Utilization of EndoFLIP to diagnose achalasia in a patient with chronic dysphagia previously attributed to dysphagia lusoria. Am J Gastroenterol. 2019;114:S1028. 2. Carlson DA, Kahrilas PJ, Ritter K, Lin Z, Pandolfino JE. Mechanisms of repetitive retrograde contractions in response to sustained esophageal distension: A study evaluating patients with postfundoplication dysphagia. Am J Physiol Gastrointest Liver Physiol. 2018;314(3):G334–G340.

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