CASE REPORT Dysphagia aortica dual aortic • •Impressions on barium swallow M N van der Ness MBChB LWStassen DMRD (Land) Department of Diagnostic Radiology University of the Free State Bloemfontein Abstract Transient intermittent oesophageal obstruction in an elderly patient is described. Barium swallow showed an extrinsic impression of the oesopha- gus by an aneurysmal aortic arch as well as the descending aorta. The aeti- ology and likely differential considera- tions are discussed. Introduction Aneurysms of the aortic arch and descending aorta can cause consider- able localised displacement of the oesophagus. Dysphagia due to all types of thoracic aortic aneurysm is uncommon but well documented. The incidence has been reported to approximate 5%.\ We present a patient with two separate impressions on either side of the oesophagus due to a thoracic aortic dilatation. Case report An 84-year-old woman on treat- ment for hypertension, ischaemie heart disease and osteoporosis, pre- sented with a 6-month history of dys- phagia and weight loss. On examina- tion the patient had kyphosis and a pulsatile epigastric mass. A barium swallow clearly demonstrated a left- sided extrinsic impression, which was due to aneurysmal dilatation of the aortic arch. A second right-sided extrinsic impression of the lower oesophagus was also demonstrated (Figs la and lb). The impression was pulsatile and was caused by the descending aorta. Discussion The aorta is attached to the oesophagus by fibrous tissue. Elongation and unfolding of the age- ing-descending aorta is accompanied by displacement of the oesophagus from its usual course. Dysphagia aor- tica can be caused by compression of either the upper oesophagus by a tho- racic aneurysm or the lower oesopha- gus by an aneurysmal or atheroscle- rotic aorta. In our patient both these impressions could be demonstrated. Dysphagia aortica is associated with hypertension, old age, and kyphoscol- iosis.' Only 10 cases of dysphagia aor- tica were identified from a Medline search of the last 10 years and a litera- 33 SA JOURNAL OF RADIOLOGY • June 2002 Figs te and lb. AP view barium swallow demon- strates dual aortic impressions. ture review compared with 40 cases of compression by an aberrant subcla- vian artery,' Fluoroscopy of the bari- um-filled oesophagus shows trans- mitted pulsations. The distal oesopha- gus is narrowed in one plane by this extrinsic compression, and obstruc- tion in the erect and supine positions may be relieved by turning the patient prone. Complete occlusion of the dis- tal oesophagus is a rare manifestation of a saccular thoracic aortic aneurysm.' The barium swallow will show a classic feature of achalasia, that is a dilated atonic oesophagus with a nar- row tapered point at the cardia. Manometry, which differentiates dys- phagia aortica from achalasia, shows low amplitude propagated peristaltic waves in the proximal part of the oesophagus and a high-pressure band at the site of the vascular compression. This contrasts with true achalasia in which there are no propagated con- tractions and no superimposed pulsa- tions. It is important to remember that diffuse infiltrating adenocarcinomas of the gastro-oesophageal junction can mimic the radiological and manometric features of true achalasia CASE REPORT by mechanical obstruction of the dis- tal oesophagus, as weU as infiltration and destruction of the myenteric plexus by the tumour,' This condition, termed pseudoachalasia, must be excluded before making a diagnosis of either classic achalasia or dysphagia aortica. There is no single test for pseudoachalasia, but high resolution CT, MRI, endoscopic ultrasound and careful endoscopic biopsy specimens from the area can be used to make the diagnosis. Dysphagia aortica should be con- sidered in any elderly patient with dysphagia who also has an aortic aneurysm. The radiographic appear- ance, however, needs to be distin- guished from achalasia or an obstructing distal oesophageal neo- plasm. References 1. De Bakey ME, McCollum CH, Graham JM. Surgical treatment of anuerysm of the descend- ing thoracic aorta. J Cardiovasc Surg 1978; 19: 571-576. 2. McMillian IKR, Hyde 1. Compression of oesophagus by aorta. Thorax 1969; 24: 32-38. 3. Taylor CW, Sinha A, Nightingale JMD. Dysphagia and thoracoabdominal aneurysm. Postgrad Med ]2001; 77: 257-258. 4. Mayer RC. Frank E. Saccular aortic aneurysm causing complete distal esophageal obstruction. Sal/th Med 11993; 86: 1408-1410. 5. Robertson CS, Gri.ffith CDM, Atkinson M, Hardcastle JD. Pseudoachalasia of the cardia: a review. JR Soc Med 1988; 81: 399-402. CT of the Head and Spine Nowinski This book provides the essential information needed for formulating findings in CT of the head and spine. 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