Images in Clinical MedicineN Engl J Med 2014; 371:e33November 20, 2014
A 74-year-old man presented with a 30-year history of intermittent dysphagia and regurgitation, which his doctor had initially referred to as a “hysterical reaction.” The patient reported having symptoms of retrosternal fullness leading to regurgitation every 2 to 3 months; he had no associated chest pain, weight loss, or change in symptom frequency over this 30-year period. A proton-pump inhibitor had been prescribed 3 years before presentation and did not provide relief. The patient was referred for evaluation. A barium-swallow examination showed two diverticula proximal to the marked corkscrew appearance of the distal esophagus (Panel A). The lumen was identified on endoscopy, but advancement of the endoscope was not possible owing to esophageal tortuosity (Panel B). Manometry was suggested to assess for diffuse esophageal spasm, but it could not be performed. The patient's symptoms remain unchanged, with infrequent dysphagia. He is relatively asymptomatic between episodes and has declined the use of other therapies, such as smooth-muscle relaxants.Chin Yit Soo, M.B., Ch.B.
University of Edinburgh, Edinburgh, United Kingdom
Jonathan Fletcher, M.R.C.P.
Borders General Hospital, Melrose, United Kingdom