A very unusual cause of dysphagia: mantle cell lymphoma.

Dysphagia is an alarm symptom requiring a prompt investigation. Different benign and malignant diseases may present such a symptom. We describe a case of a 79-year-old patient who complained of fluctuating dysphagia episodes following solid food ingestion in the previous 5 months with mild weight loss. No other gastrointestinal symptoms were present. The patient was referred by the General Practitioner for a videofluoroscopic swallow examination which revealed nodularity of mucosa surface in the oropharynx, esophagus, fundus, and gastric body. Upper endoscopy confirmed the feature, also showing a normal mucosa of the antrum and duodenum. The histological examination revealed a mantle cell lymphoma (MCL). A stage III, MCL involving the esophagus and proximal stomach was eventually diagnosed. Esophageal MCL localization is extremely rare, and this is the first report showing a clinical onset with dysphagia.

Pseudoachalasia: A peculiar case report and review of the literature.

Pseudoachalasia is a rare secondary achalasia, which accounts for only a small subgroup of patients. We describe a 77-year-old woman with recent onset of dysphagia and typical esophageal manometric findings of achalasia. Moreover, esophageal manometric findings of vascular compression at 36 cm from the nose were associated with dysphagia. An upper endoscopy showed the absence of lesions both in the esophagus and gastro-esophageal junction, whilst a 15-mm ulcer on the gastric angulus was detected. The gastric ulcer resulted in being a diffuse signet ring cell carcinoma at histology, suggesting pseudoachalasia. An abdominal computed tomography scan showed an irregular concentric thickening of the gastro-esophageal junction wall extending for 7 cm and a dilated ascending thoracic aorta with no presence of the inferior vena cava, with an enlarged azygos as the source of vascular compression of esophagus. Moreover, cardia involvement from diffuse signet ring cell carcinoma of the gastric angulus was also recognized as the cause of dysphagia. The cancer was not suitable for a surgical approach in an old patient with cardiovascular comorbidities and support therapy was started. In our ambulatory series, pseudoachalasia was eventually diagnosed in 4.7% of 234 consecutive patients with esophageal manometric finding suggestive of achalasia. We also reviewed cases in the literature and aimed to evaluate the reported causes of pseudoachalasia.

Palliation with oesophageal metal stent of pseudoachalasia from gastric carcinoma at the cardia: a case report.

We present an 82-year-old woman with a 3-month history of progressive dysphagia and a normal initial upper gastrointestinal endoscopy. The diagnosis of pseudoachalasia was suspected by oesophageal manometric and barium swallow studies, and confirmed by biopsies revealing an intestinal type carcinoma of the stomach at a repeated endoscopy. In view of the history of heart disease, diabetes, and old age, this patient was treated by a partially covered Ultraflex self-expanding metal stent (Boston Scientific, Natick, MA, USA) placed into the oesophageal body with no direct complications and obtaining the relief from dysphagia. During the 11-month follow-up she was treated for an iron deficiency anaemia due to reflux oesophagitis with ulcerations in the oesophageal body and died from myocardial infarction. According to the localization of the cancer, the old age, and the presence of comorbidities, we should recommend the insertion of a partially covered self-expanding metal stent as a reasonable palliative treatment in selected subjects with pseudoachalasia.

Computed tomography enteroclysis in comparison with ileoscopy in patients with Crohn's disease.

BACKGROUND AND AIMS: Enteroclysis and computed tomography (CT) have been recently combined in to assess small bowel alterations. We compared the accuracy of CT enteroclysis to that of endoscopy in detecting bowel wall alterations of the terminal or neoterminal ileum in Crohn's disease (CD) patients and assessed whether postcontrast wall density is related to clinical activity of CD. PATIENTS AND METHODS: A total of 39 patients referred for either established or suspected CD were enrolled. Diagnosis used ileocolonoscopy with histology; clinical activity was measured by CDAI. Contrast-enhanced spiral CT of the abdomen was performed after distension of the small bowel with an enema of methylcellulose. Retrograde ileocolonoscopy diagnosed 30 patients with CD of the ileum, while 9 patients served as controls. RESULTS: CT enteroclysis detected CD in 26 patients (86.7%) and in none of the control group. Three of four patients with false-negative findings on CT enteroclysis had postsurgical CD recurrence. The overall sensitivity and specificity of CT enteroclysis for ileal CD detection were 86.7% and 100%, respectively (PPV=100%; NPV=69.2%), and 94.1% and 100% (PPV=100%; NPV=90%), excluding those patients with postsurgical recurrence. The postcontrast wall density was significantly higher in CD patients than in the controls and was significantly correlated with the severity of CD. CONCLUSION: CT enteroclysis proved highly accurate in detecting terminal ileal CD involvement, particularly in patients without previous surgery, and to allow assessment of the degree of intramural and clinical activity.

Quality of life after conservative laryngeal surgery: a multidimensional method of evaluation.

Assessment of quality of life (QoL) and satisfaction with care are particularly important in the field of oncology. The definition of QoL and the requirements for its measurement are still a matter of debate, but it is generally accepted that QoL is a multidimensional concept involving three different domains: physical, psychological and social. The aim of this study was to test a simple, inexpensive, multidimensional method of QoL measurement, based both on patients' perception of clinical outcome and the quantitatively evaluated clinical outcome, equally weighted, in patients who underwent three different types of conservative laryngeal surgery: horizontal laryngectomy (HG), supraglottic laryngectomy (SL) and subtotal reconstructive laryngectomy (SRL). The following were carried out for each patient: subjective-objective evaluation of speech [computerized spectrographic analysis of fundamental frequency (FO), percentage of noise and intensity and logopedic evaluation of speech], evaluation of deglutition (videofluoroscopic parameters, and qualitative assessment) and evaluation of physical, social, emotional and functional well-being (Functional Assessment of Cancer Therapy, FACT-G, and modified University of Washington Quality of life Scale, UWQoL). Each assessment was given a score rating from one to three points. The overall evaluation of the qualitative and quantitative score for each field and for each type of laryngeal surgery shows that SL results in the best post-operative QoL. Although HG is less damaging and involves swifter functional recovery times, its slightly lower score is due to the poorer quality of speech. The analysis of the results obtained confirm the need to set up an evaluation protocol combining both the subjective perceptions of the patient, as well as the more objective evaluation of the functions that are impaired following surgery. The protocol described above, although limited by the low number of cases, was easy to carry out, inexpensive and applicable in relation to the various types of surgery that may compromise phonation and deglutition.