This week, we are sharing another OMM-style practice question to test your knowledge of medical topics. Today’s case focuses on a 56-year-old man who has difficulty swallowing. He has a history of jitteriness. Which of the following best describes the affected anatomic site that most likely resulted in this patient’s clinical symptoms? Can you figure it out?
A 56-year-old man presents to his primary care physician for evaluation of difficulty swallowing. Over the past several weeks, the patient has had the sensation of “food getting stuck” as he swallows. He also has a new history of intermittent “jitteriness.” Medical history is notable for long-standing hypertension, hyperlipidemia, diabetes, and esophageal reflux. The patient’s medications include metoprolol, metformin, atorvastatin, and omeprazole. He has a history of medication non-compliance. Temperature 37.0°C (98.6°F), pulse is 89/min, respirations are 16/min, and blood pressure is 177/92 mmHg. The patient’s physical examination is unremarkable. A portion of the patient’s telemetry strip is demonstrated below. Which of the following best describes the affected anatomic site that most likely resulted in this patient’s clinical symptoms?
Image reproduced from Wikimedia Commons
A. Level of the left atrium
B. Level of the cricopharyngeal muscleC. Level of the aortic arch
D. Level of the left main bronchusE. Level of the diaphragm
Scroll down to find the answer!
The correct answer to today’s OMM® Question is…
A. Level of the left atrium
Before we get to the Main Explanation, let’s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
The incorrect answers to today’s OMM® Question are…
B. Level of the cricopharyngeal muscle
Incorrect: Food impaction and stricture formation may result at the esophageal level of the cricopharyngeus muscle. However, this patient’s clinical presentation and ECG is more consistent with impaction at the level of the left atrium secondary to atrial dilation and associated compression of the esophagus.
C. Level of the aortic arch
Incorrect: Aortic arch dilation from aortic dissection or aortic aneurysm may impede the esophagus at this level. However, this patient’s clinical presentation and ECG is more consistent with impaction at the level of the left atrium secondary to atrial dilation and associated compression of the esophagus.
D. Level of the left main bronchus
Incorrect: Impingement at the level of the left main bronchus may occur from mass effect due to associated trauma or tumor burden. However, this patient’s clinical presentation and ECG is more consistent with impaction at the level of the left atrium secondary to atrial dilation and associated compression of the esophagus.
E. Level of the diaphragmIncorrect: Esophageal constriction may occur at the diaphragm level due to long-standing esophageal reflux disease and associated stricture formation. Typically, affected individuals will have evidence of untreated disease, including epigastric pain, a metallic taste in the mouth, or a history of gastritis or peptic ulcer disease. This patient’s clinical presentation and ECG is more consistent with impaction at the level of the left atrium secondary to atrial dilation and associated compression of the esophagus.
Main Explanation
This patient presents for dysphagia evaluation and is found to have new-onset atrial fibrillation. Although rare, atrial fibrillation and associated left atrial dilation can result in compression of the esophagus and subsequent food impaction.
The esophagus has multiple compression sites as it courses from the oropharynx to the stomach. Superiorly, the esophagus may constrict as it enters the mediastinum, where the cricopharyngeus muscle may cause constriction. Thoracic constrictions occur where the arch of the aorta crosses the esophagus or at the levels of the left main bronchus and the left atrium. Lastly, the esophagus may constrict crossing the diaphragm.
Pathologic insults at any anatomic site can ultimately slow the passage of solid foods and liquids. Over time, these insults can lead to esophageal stricture formation.
Major Takeaway
The esophagus has multiple compression sites as it courses from the oropharynx to the stomach. These include the cricopharyngeus muscle, aortic arch, left main bronchus, left atria, and esophageal hiatus.
References
Cheng, H.T., Cheng, C.L., Lin, C.H., et al. (2008) Caustic ingestion in adults: The role of endoscopic classification in predicting outcome. BMC Gastroenterology. 8, 31. Doi: 10.1186/1471-230X-8-31.
Smith, C.D. (2015) Esophageal strictures and diverticula. The Surgical Clinics of North America. 95(3), 669-681. Doi: 10.1016/j.suc.2015.02.017.
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