A 28-year-old female patient suffered from postprandial lower chest pain and heartburn for more than one year. Her past medical history and family history were unremarkable. She lost 4 kilograms and did not experience dysphagia or regurgitation. Three months before her visit to our hospital, the pain had become more severe. The upper gastrointestinal endoscopy (UGIE) performed at another hospital showed a lower esophageal ulcer, which was located just above the gastroesophageal junction, hiatal hernia, and antral-predominant gastritis (Figures 1(a) and 1(b)). The H. pylori antibody test was positive, and the histological result of esophageal ulcer was benign. The patient received H. pylori eradication therapy followed by a regimen of proton pump inhibitor (PPI) at a standard dose in combination with antacid for more than 8 weeks. However, her pain did not resolve and she sought for medical consultation in our hospital.
We managed the patient as a case of refractory GERD. At first, the patient was treated with rabeprazole 20 mg bid in combination with alginate-antacid at bedtime for 2 weeks. The pain improved but was still intolerable and badly affected her sleep quality. The regimen was switched to rabeprazole 20 mg bid in combination with amitriptyline 12.5 mg at bedtime, which resulted in a complete clinical response and was continued for 10 weeks. The dose of rabeprazole was then tapered to 20 mg qd aiming to stop completely before UGIE was performed to document the efficacy of treatment. However, the pain recurred badly after about a week. The patient requested us return to double-dose rabeprazole, which again relieved the pain.
The second UGIE performed when the patient was still on PPI showed that the lower esophageal ulcer had completely healed (Figures 1(c) and 1(d)). There was a protrusion at the cardia, which was only identified when air was minimum insufflated, suspected of a submucosal lesion. Endoscopic ultrasound (EUS) and CT scan were performed which surprisingly showed a giant submucosal tumor at the fourth layer of the lower esophagus and the cardia (Figures 2 and 3). EUS-FNA was performed, and the histological examination confirmed that this lesion was a leiomyoma (Figure 2).
The patient was performed laparoscopic transhiatal surgery to enucleate the esophageal leiomyoma. In addition, hiatal hernia was repaired with laparoscopic Nissen fundoplication (Figure 4). As the tumor is too large, it was cut into pieces to facilitate its removal. The solid straightened tumor was approximately 8 cm x 3 cm in size (Figure 4). The patient made an uneventful postoperative recovery. During the first two weeks, she had experienced dysphagia and regurgitation, which have resolved completely.
Four months after her surgery, UGIE was performed again which showed good results of fundoplication surgery (Figures 1(e) and 1(f)). The patient sometimes had epigastric pain which could be completely controlled with intermittent rabeprazole therapy at a standard dose.