A 50-year-old male with epilepsy presented with a 5-year history of dysphagia. Since temporal lobectomy 12 years prior, his seizures were well controlled on 6 tablets daily of phenytoin 100 mg. His dysphagia was insidious, progressive, and most notable with solids such as bread, rice, and meats. The patient reported no difficulty swallowing liquids. He had the sensation of the pills feeling "stuck" in his chest when taking phenytoin without water. Additionally, he had chest pain and heartburn partially relieved with a proton pump inhibitor. The patient denied alcohol or tobacco use, radiation exposure, or a history of cancer.
Barium esophagram exhibited a fixed, irregular, long-segment, mid-esophageal stricture. Multiple small (<2 mm) outpouchings filled with barium contrast were scattered throughout the proximal esophagus. The 13-mm barium pill failed to traverse the stricture (Figure 1). Upper endoscopy revealed an abnormal esophagus with the exception of the proximal and distal 5 cm. The mucosa appeared pale and thick with pitting and scars (Figure 2). The mid-esophagus from 28 to 35 cm from the incisors had a thick stricture with multiple intramural pseudodiverticuli and occasional white punctate exudate (Figure 2). Savary dilation to 14 mm was performed with moderate resistance to allow passage of the scope.
The patient was switched from phenytoin tablets to a liquid preparation to prevent further injury. He was instructed to take medication with a copious amount of water while in an upright position to prevent further damage, and to continue to take a proton pump inhibitor. His dysphagia improved after dilation and we intend to perform serial dilations of the stricture.