dysphagia is the subjective awareness of difficulty in the passage of solids or liquids from the oropharynx to the stomach .
dysphagia can be classified into an oropharyngeal or an esophageal location , and it is caused by neuromuscular motility disorders and mechanical obstruction.1 ) mechanical dysphagia is associated with intrinsic or extrinsic compression , resulting in progressive intolerance to solids . the term , dysphagia aortica , has been used to describe difficulty in swallowing caused by external compression from an ectatic , tortuous , or aneurysmal aorta as a result of age - related degeneration.2 ) dysphagia aortica is classically seen in elderly women with short stature who have hypertension and kyphosis.3 ) we report herein a patient with dysphagia associated with an aortic aneurysm .
an 86-year - old woman presented with worsening nausea and vomiting . because of her progressive dysphagia to solids for the last 6 months , she had ingested only semisolids and liquids .
three days before seeking evaluation at our hospital , she had difficulty in swallowing liquids , along with nausea and vomiting .
the medical history revealed that she had been diagnosed with primary hypertension , an ascending aortic aneurysm , congestive heart failure , moderate aortic regurgitation , and moderate mitral regurgitation 6 years previously . because of old age
she had undergone vertebroplasty due to multiple compression fractures of the thoracic and lumbar vertebrae 5 years ago . on admission to the hospital
the blood pressure was 130/90 mmhg , the pulse rate was 64 beats / min , the respiratory rate was 28 breath / min , the body temperature was 36.0 , the height was 1.43 m , and the body weight was 37 kg .
the physical examination showed a diastolic murmur at the right upper sternal border and a pansystolic ejection murmur at the left lower sternal border .
the laboratory findings were as follows : the white blood cell ( wbc ) count was 5,100/mm , the hemoglobin was 11.8 g / dl , the platelet count was 151,000/mm , the blood urea nitrogen ( bun ) was 39.8 mg / dl , the creatinine was 1.5 mg / dl , the total protein was 5.8 g / dl , the albumin was 3.2 g / dl , the lactate dehydrogenase ( ldh ) was 546
her chest radiograph revealed blunting signs at both costophrenic angles , cardiomegaly with a cardio - thoracic ratio of 0.8 , and an enlarged , tortuous aorta ( fig .
1 ) . computed tomography ( ct ) of the chest demonstrated an enlarged , tortuous aorta ( fig .
the diameters of the ascending thoracic aorta , the descending thoracic aorta , and the proximal abdominal aorta were 7 cm , 6 cm , and 5.3 cm , respectively .
the upper gastrointestinal barium study revealed marked extrinsic compression of the distal esophagus just above the esophagogastric junction ( fig .
we concluded that the symptoms and the results of the imaging studies were consistent with dysphagia aortica .
although we recommended surgical correction of the aortic aneurysm or percutaneous endoscopic gastrostomy , the patient declined any invasive procedures and she was transferred to a nursing home on the 12 hospital day .
the esophagus normally begins on the right side of the thoracic aorta and then descends .
then , the esophagus lies on the left side of the aorta and penetrates the diaphragm through the diaphragmatic histus.4 ) the aging process and the accompanying degenerative changes with the loss of elasticity causes a dilated , elongated , and distorted aorta , which may result in a so - called reverse c- or reverse s - shaped aorta.3 ) as a result , the esophagus is pushed and compressed by the aorta against the cardiac chambers , which are anterior in location.5 ) there is no gold standard diagnostic procedure for dysphagia aortica .
the association of suggestive symptoms , such as progressive intolerance to solids with concomitant weight loss along with the results of imaging and other diagnostic studies provide a high index of suspicion.6 ) the diagnostic work - up includes radiologic , endoscopic , and manometric studies . on a standard chest radiography and ct scan , the enlargement of the aortic arch and the tortuous dilated aorta can be observed .
a barium swallow test may show partial esophageal obstruction and pulsatile movement of the barium synchronous with aortic pulsation.7 ) endoscopy reveals pulsatile extrinsic compression and stenosis of the lower esophagus with proximal dilatation .
esophageal manometry may demonstrate a localized high pressure band with superimposed pounding that is synchronous with the cardiac pulsation.8 ) however , the typical findings of dysphagia aortica can be inconsistent .
the radiographic findings are often inconclusive because a dilated , tortuous thoracic aorta is frequently encountered in elderly patients with dysphagia .
although a ct scan is useful for evaluating not only the aortic lumen , but also the aortic wall,9 ) occasionally this is of no value in assessing compression of the esophagus by the aorta.2 ) false negative results are common for barium swallow studies .
in addition , the classical manometric features suggestive of dysphagia aortica also occur in normal subjects.8 ) the differential diagnosis of dysphagia aortica includes various common structural and neuromuscular abnormalities.1 ) gastroesophageal reflux disease and motility disorders are common causes of dysphagia .
the co - existence of these conditions and the lack of sensitivity and specificity of the usual diagnostic tests make it difficult to diagnose dysphagia aortica with certainty .
wilkinson et al.2 ) demonstrated that a video solid bolus swallow test could be useful in determining the manometric findings that are suspicious for dysphagia aortica when the standard evaluation fails .
mild cases may be treated conservatively , such as avoiding sticky solids and feeding on a liquid diet .
the surgical procedures include transposition of the distal esophagus , separation of the distal esophagus from the aorta , esophagomyotomy , division of the right crus of the diaphragm , aortic resection , and repair of an aneurysm . for patients who are not candidates for surgery , insertion of a feeding tube via percutaneous endoscopic gastrostomy ( peg )
although we did not perform esophageal manometry , the patient 's symptoms and imaging studies were consistent with the classic findings of dysphagia aortica .
although the patient declined any invasive procedures , a peg for a feeding tube might have been helpful for nutritional support .
dysphagia aortica is an uncommon type of dysphagia that is caused by extrinsic mechanical compression .
it should be differentiated from other causes of dysphagia , such as gastroesophageal reflux disease or motility disorders , because dysphagia aortica often requires surgical intervention that can significantly reduce the morbidity and these interventions can be curative in some situations .
 dysphagia aortica is difficulty in swallowing caused by extrinsic compression of the esophagus due to an ectatic , tortuous , or aneurysmatic atherosclerotic thoracic aorta . 
 this condition is very uncommon , and it is usually associated with old age , women with short stature , hypertension , and kyphosis . 
 we report herein a case involving a patient with dysphagia who had an aortic aneurysm . 
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