A 55-year-old female presented with progressive dysphagia to solids and lost 10 kg weight over two years. She had heartburn and epigastric burning pain during the past 5 years, for which she took over-the-counter acid-suppressive medications. She denied a history of ingesting a caustic substance, radiotherapy, atopy, and other comorbid illnesses. None of her family members had any gastrointestinal disease. She was neither an alcoholic nor a smoker. On examination, she was pale and ill-nourished. She did not have significant lymph node enlargement. Examination of the abdomen, cardiovascular and respiratory systems was unremarkable. Blood investigations showed hemoglobin 8.8 gm/dL, total leukocyte count 6.4 x 109/L, platelet counts 510 x 109/L, and serum ferritin 8.1 microg/L. Peripheral smear showed microcytic and hypochromic red blood cells. Barium swallow showed a 3 cm x 2 cm sized diverticulum from the right lateral wall of the cervical esophagus and a short segment narrowing in the distal esophagus with upstream dilation (Fig. 1). We initially suspected gastroesophageal reflux disease (GERD) with peptic stricture of the esophagus; however, we wanted to rule out underlying malignancy because of profound weight loss and anemia. Hence a computed tomography (CT) scan of the neck and thorax was done, which confirmed KJD and showed a homogenous circumferential wall thickening in the lower esophagus with no significant periesophageal lymph nodes (Fig. 2).
Esophagogastroduodenoscopy revealed KJD at 20 cm from incisors and a tight stricture at the lower esophagus beyond which the endoscope was not negotiable (Fig. 3). The stricture was dilated with a controlled radial expansion (CRE) balloon up to 12 mm (Fig. 3). Biopsies from the stricture site were negative for malignancy. We considered peptic stricture and malignancy of the distal esophagus in the differential diagnosis. Though profound weight loss and anemia raised suspicion of malignancy, the long duration of symptoms, benign CT scan characteristics, and biopsy from the stricture site confirmed peptic stricture in this case. The upper esophageal diverticulum in barium swallow and endoscopy prompted us to consider ZD, KJD, and LD. However, the CT scan confirmed the origin of the diverticulum from the anterolateral wall of the esophagus below the cricopharyngeus muscle. Hence, a final diagnosis of KJD and peptic stricture was made. The patient underwent three CRE balloon dilatation sessions from 12 to 15 mm at 4-weeks intervals. Post dilatation, she was started on capsule omeprazole 20 mg twice daily along with hematinics. After 6 months, she gained 7 kg weight, could take feeds normally, and her repeat hemoglobin was 10.9 gm/dL. She is currently doing well during follow-up.