Diagnostic dilemmas in dysphagia aortica

Abstract

Objective: Dysphagia aortica describes swallowing difficulty caused by external compression from a tortuous or aneurysmal aorta. We present 5 cases in which dysphagia to solids accompanied a localised high pressure barrier (HPB) on manometry suggestive of dysphagia aortica, and explore other investigation modalities useful to confirm the diagnosis.

Methods: Four females and 1 male with a median age of 56 years (range 47-58) were investigated. All underwent investigation with endoscopy, chest radiography, CT scanning, barium swallow, and video solid bolus swallow in addition to oesophageal manometry and 24 h ambulatory pH monitoring.

Results: Median basal pressure rise at the mid oesophageal HPB was 45 mmHg (range 40-80). In addition to the HPB, 4 patients had manometric abnormalities of swallow activity and 2 patients had significant gastroesophageal reflux disease (GORD). Contrast enhanced computed tomography and barium swallow were normal in all cases. Video bolus swallow showed pronounced obstruction to transit at the aortic arch in 2 cases and excluded significant dysphagia aortica in 2 others.

Conclusions: Dysphagia aortica commonly coexists with motility disorders and GORD. Video solid bolus swallow allowed us to determine the clinical significance of a manometric HPB in 4 out of 5 patients suspected on dysphagia aortica where standard evaluation would have failed. We recommend its use in those patients with a manometric HPB suggestive of dysphagia aortica in whom standard barium swallow is normal.