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Case 353

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Male patient, 66 years old, from the region of Itabira, presents progressive dysphagia for 5 years, evolving with regurgitation, heartburn, tolerance for pasty food and liquids only, and involuntary weight loss of 10kg. The patient has a cardiac pacemaker and hypertension, with history of smoking (56 pack years) and alcoholism. Upper gastrointestinal endoscopy (UGIE): dilated esophagus, with high quantity of aspirable clear residue. Esophagogram with barium sulfate requested.

Considering the clinical and radiological findings, what is the most likely diagnosis?

a) Esophageal carcinoma

25%

b) Chagas megaesophagus group III (Rezende's Classification)

25%

c) Pseudoachalasia secondary to esophageal carcinoma

25%

d) Chagas megaesophagus group IV (Rezende's Classification)

25%
   

Image analysis

Image 1: Esophagogram with barium sulfate, patient in orthostatism, posteroanterior view. Narrowing of the esophagus extremity (red arrow) conditioning large retention of contrast agent upstream and consequent increase in caliber (yellow arrow), as well as small tertiary waves (blue arrow). Extremity of the ventricular lead of cardiac pacemaker (green arrow).

Highlights

         - The physiopathology of the chagasic esophagopathy includes the denervation of the myenteric plexus and sphincter injuries that result in stasis;

        - 30-50% of the patients evolve to the chronic phase of the Chagas disease, in the forms: cardiac, digestive or mixed;

        - The main clinical manifestation of the Chagas megaesophagus is the progressive dysphagia that begins with solids;

        - The esophagogram allows to classify the severity of the megaesophagus (Rezende's classification) and guide the therapeutic;

        - The treatment is palliative, aiming the improvement of the dysphagia.

References

        - Brasileiro Filho G. Bogliolo Patologia. 8th ed. Grupo Gen - Guanabara Koogan; 2000;

        - D'Ippolito G, P. Caldana R. Gastrointestinal - Série Colégio Brasileiro de Radiologia e Diagnóstico por Imagem. 2nd ed. Rio de Janeiro: Elsevier Editora Ltda, 2011;

        - Coura J, Dias J. Clínica e terapeÌ‚utica da doença de Chagas: uma abordagem prática para o clínico geral. SciELO; 1997;

        - Carlos Pinto Dias J, Novaes Ramos A, Dias Gontijo E, Luquetti A, Aparecida Shikanai-Yasuda M, Rodrigues Coura J et al. II Consenso Brasileiro em Doença de Chagas, 2015. 2016;

        - Abud TG, Abud LG, Vilar VS, Szejnfeld D, Reibscheid S. Alterações radiológicas encontradas no megaesôfago chagásico em radiografias simples de tórax e esofagogramas. Radiol Bras. 2016 Nov/Dec; 49(6):358–362;

        - Laurino-Neto RM, Herbella F, Schlottmann F, Patti M. Avaliação diagnóstica da acalásia do esôfago: dos sintomas à classificação de Chicago. ABCD Arq Bras Cir Dig. 2018;31(2):e1376. DOI: /10.1590/0102-672020180001e1376.

Author

Gabriella Yuka Shiomatsu, 4th year medical student at Universidade Federal de Minas Gerais (UFMG).

E-mail: gabriellashiomatsu[at]gmail.com

Supervisor

Soraya Rodrigues de Almeida Sanches, surgeon of the esophagus, stomach and duodenum group from the Alpha Institute of Gastroenterology of the UFMG's Clinical Hospital and associated professor of the Surgery Department of the Medicine Faculty of UFMG.

E-mail: srasanches[at]gmail.com

Reviewers

Letícia de Melo, Maria Cecília, Mateus Nardelli, Fernando Amorim, Professor José Nelson Mendes Vieira, Professor Viviane Santuari Parisotto Marino.

Translated by

Gabriella Yuka Shiomatsu, 4th year medical student at Universidade Federal de Minas Gerais (UFMG).

E-mail: gabriellashiomatsu[at]gmail.com

Test question

[UFT Medical Residency 2014 - Trauma and Vascular Surgery] Concerning the chagasic megaesophagus, we can affirm that:

a) The upper gastrointestinal endoscopy has a high sensitivity and specificity for its diagnosis, allowing the classification according to the degree of dilation.

25%

b) Endoscopic treatment with dilation and injection of botulinum toxin is used in any phase of the disease, being superior to surgical results.

25%

c) Patients with low surgical risk must be submitted to esophagectomy, since the disease raises the risk of esophageal cancer.

25%

d) The radiological exam with oral contrast must be avoided due to the high risk of bronchoaspiration.

25%

e) The upper gastrointestinal endoscopy is indispensable for the evaluation of the esophageal mucosa, in the patients with chagasic megaesophagus.

25%
   

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