A case of dysphagia

Esophageal strictures commonly complicate radiation therapy for neck and thoracic malignancies. We here report a case of radiation induced stricture esophagus and illustrate the classical barium esophagogram in this condition. 58 year old male with past history of carcinoma esophagus treated with radiotherapy had presented with recurrence of dysphagia. Dysphagia was insidious in onset and was predominantly for solids than liquids. Physical examination was normal except for gross emaciation. Hemogram and routine biochemical panel were within normal limits. Barium swallow revealed significant mid-esophageal luminal narrowing with significant contrast pooling above. Upper gastrointestinal endoscopy revealed luminal narrowing at 25cms from the incisors; it was not possible to negotiate through the stricture. At endoscopy mucosa appeared normal except for minimal erythema. Mucosal biopsies revealed only normal stratified squamous epithelium and no evidence of neoplasm. Contrast computed tomography revealed no evidence of tumor recurrence or metastasis or lymphadenopathy. Patient was managed with serial dilatation with Savary Guillard dilators. Patient improved with treatment and is currently able to take oral feeds. Stricture is commonly reported to develop in 2-3 weeks to 4-8 months after radiation exposure, though late presentations also can occur. In patients presenting with dysphagia following radiotherapy for carcinoma esophagus it is always important to rule out residual or recurrent neoplasm with endoscopy and imaging. Esophageal dilatation with or without stenting is the current treatment of choice.

She dates the origin of her complaints from a violent attack of cynanche maligna near twelve years ago, to the contagion of which file was expofed almoft immediately after her recovery from a fevers parturition, During the whole term of, and indeed for fome years previous to, utero-geftation, her health was extremely delicate, and at times interrupted by alarming pulmonic affedtions, which it was feared would terminate in phthifis. The molt prominent features of her diforder from that period till the expiration of more than three years, were a flight though progreffively increafed difficulty of Fwallowing, accompanied with fome degree of forenefs, and an augmentation of the falival excretion. With a view to the palliation of thefe fymptoms, fhe was directed to have occafional recourfe to aperients, leeches, blifters, and gargles. By this time, however, the difficulty of deglutition had become fo alarmingly exafperatcd, that fhe was 110 longer capable of fwallowing folids, even of the magnitude of a field pea. In this fituation (lie put herfelf under the direction of Dr. Smith, late of Nottingham, who very judicioufly prefcribed mercurials. A molt fevere falivation was.the confequence, under which fhe laboured for the protracted fpace of three months. By this method the fymptoms were io confiderably alleviated, that fhe was capable once more of fwallowing foft and well comminuted folids. But though thus refcued from her impending fate, the remedy was productive of effects no lefs formidable. I allude to cxceffive debility, frequent fyncope on the leaft motion, colliquative iweats, her fyftem being greatly emaciated, and a prey to hyiterical paroxyfms. By the aid of proper dietetical management, as the complaint it was vainly hoped was fubdued, her attendants flattered themfelves fhe might ftill furvive even this fevere conteft. Alas! no fboner were her drooping fpirits reanimated by the fenfible acquifition of renovated vigour, than the fond expectations fhe had cherifhed became deprefled by a vifible return of her former impediment to fwallowing.
During the laft feven years, fhe found herfelf reduced to the fad neceility of fupporting a miferable exiftence by means of liquid aliment, fuch as foups, milk, &c. I faw her for the firft time in the beginning of October, j8oi, in confequence of her having been choalced by inadvertently attempting to fwallow a morfel of bifcuit foaked in tea, not equal in fize to a grain of wheat.
Several efforts indeed now became neceflary to enable her to fwallow a tea fpoonful of any liquid, a part of which regurgitated feveral times before the whole defcended into the Itomach, and the pain produced by the effort was fo fevere, as not unfrequently to ufher in a general convulfive agitation of fome continuance. She had then a dejedted emaciated appear-ance3 ance, a quick pulfe, and other hectic fymptoms, and was harrafied by an almofi: inceflant ptyalifm, more particularly urgent during the earlier part of the day, at which time file was always hoarfe. The breathing was much incommoded when file reclined on a fofa or bed, which concurred with the other fymptoms in rendering her nights very reftlefs. Her bowels were habitually inactive. She exprefied a keen fenfe of hunger, but her cafe in this refpedt was fimilar to the poetic fidtion of Tantalus, alluded to by Horace, te Tantalus a labris fitiens fugientia captat " Flumina. " Though equally alive to all the wants of fainting nature, and folicited to relieve them by a copious board, file was doomed to experience the extremity of feeling, without the pofiibility of gratifying thofe fenfations. There was not any external tumefaction of the thyroid gland, nor could the obftructed part be obferved by infpedting the fauces. Dyfphagia in this inveterate ftage, has I believe hitherto almoft invariably bidden defiance to the beft directed medical expedients; and the Angularity of the cafe will, I trufi, be deemed a fufficient apology for the minutenefs of its defcription.
Indeed feveral eminent practitioners who had, previous to myfelf, been confulted, were unanimoufly of opinion, that file niuft fliortly and inevitably perifii from inanition. It is not my difpofition, however, to abandon hope whilft life remains j and under the fandtion of that maxim of Celfus, " Melius eft anceps remeilium quam nullum," I propofed to her, as a dernier refort, to have recourfe to mechanical dilatation, a practice none of the faculty had before even fug^efted. Senfible that if not fpeedily relieved, file muft fall a victim to this relentless difeafe, the agreed to fubmit implicitly to any plan from the adoption of which the fmalleft profpect of fuccefs might rationally be anticipated. Several considerations determined me to refort to this method.
Firfi, The fuppofition that the complaint originated in a contradtion of the circular fibres of the crfophagus, configuring a difeafe clofely analogous to urethral firidtures.
Secondly, That in fomc in fiances of this malady, when incipient, that had fallen under my care, the fubjedts of which were liable, from attempting to fwallow folids not fufficiently mafticated, to be occafionaily choaked, the probang had been introduced not only with perfect iafety, but that by feveral repetitions of the operation, the individuals, inttead of a palliative, have eventually though unexpectedly obtained a radical cure of the ftricture. D 3 Thirdly, Thirdly, Mercury, firfl: recommended by the ingenious and learned Dr. Munckley, had in this dreadful example been tried4 and though it very much mitigated for a time, yet proved ineffectual in eradicating the difeafe, notwithstanding the remedy exerted its peculiarly pernicious influence on her irritable fyftem.
v v And fourthly, That the diforder, if not fpeedily alleviated, muft prove fatal ; and this circumftance juftified me in the application of even an ambiguous remedy.
In purfuance of thefe ideas, I firft: cautioufly introduced a common bougie into the lower part of the pharynx. In this place, a powerful refinance that occurred, and which occafioned my inftrument on the application of fomewhat forcible preflure to bend in various dire&ions, feemed to confirm my theory of the nature of the difeafe-Thus foiled, I ventured to fubftitute a fmall probang copioufly charged with oil. It was not without fteady and continued efforts that this operation was made to dilate the ftri?ture. After having overcome this obftacle, the inftrument defcended without much difficulty till it reached, I fuppofe, the lower portion of the cefophagus near the cardia, when a fecond impediment announced the exiftence of another ftri&ure. The fa ne meafures however at length availed in enabling the probang alfo to force a paflage through this contracted part, when it fuddenly pafted into the ftomach. The inftrument having been deliberately withdrawn, as foon as Mrs. W. had fomewhat recovered from the irritation and fatigue produced by this procefs, I gave her fome gruel which ftood ready, in order that The might afcertain, by Tipping leilurely a fmall quantity, whether any benefit had accrued from the operation. Upon attempting to fwallow, file found the former impediment removed, and continued drinking till {he had confumed at leaft half a pint of the liquid with the greateft facility as to the power of deglutition, though of courfe fome forenefs muft have exifted.
Apprehending that the pafiage would not by the fmall inftrument employed, be fufficiently dilated to admit of the ready ingurgitation of folids, the operation was repeated with a larger inftrument three fucceflive times, a few days being fuffered to intervene between each, in order that the topical pain might be allayed by the exhibition of oily lin?tufes and aperients, and by fomentations. The fourth operation enabled her to fwallow folids without experiencing the fmalleft inconvenience, a faculty fheftill continues to exercife in its fulleft extent.
By adopting a regular fyftem of analeptics, all the he?tic fymptoms, See. fpeedily fubfided, her enfeebled conftitution foon rallied, and put her in the pofleffion of better health than {he ever enjoyed during the earlier part of her life.

As
As a further teftimony of the efficacy of mechanical means in the radical cure of this tremendous difeafe, permit me fhortly to add, that the only daughter of the above mentioned lady, aged twelve years, had from her earlieft infancy, indeed from her birth, laboured under theDyfphagia Oefophagia. Her constitution partakes much of the nervous irritability of her mother. The want of fubftantial food (for her exigence had been fupported by the fu&ion of liquid aliment alone) tended obvioufiy to retard the p'nyfical evolution of her fyflem. 1 he compleat fuccefs which had crowned my eftorts in the cafe of Mrs. W. naturally created an anxious wifh in the parents to have the fame means reforted to in the prefent inftance; of the abfolute neceffity of which my intelligent little patient v/as fully iatisfied, and readily confented to undergo the operation, from the fanguine expectation of deriving equal benefit. It is with fentiments of the greateft fatisfa?tion 1 am authoriled to ftate, that the expedient has proved altogether falutary and efficacious. The texture of her body, which previous to the operation had ever been extremely delicate, has acquired a wonderful degree of renovated vigour, and her fpirits, formerly fubject to great depreffion, have obtained fuch a healthy flow, that fhe can now engage in juvenile amulements with the greateft cheerfulnefs and vivacity.

OBSERVATIONS.
The foregoing difcafe feems decidedly a cafe of Dyfphngia Oefophagia ipecies, 5th of Sauvages, arifing from a contraction of two portions of the oefophagus. Its occurrence is by 110 means the inoft rare phenomenon in the diforders incident to the human race. Abflraited from the coniideration of pain, which is feldom confiderable, (except in inveterate cafes during the act of deglutition, when a general tremulous affection follows the attempt) it conflitutes a complaint the molt diftrefsingly formidable to the patient, from the apprehenfion of ail eventual obliteration of the paliage to the ftomach. As far as my obfervations have enabled me to form a comparifon, perfons ?f a flender make and irritable temperament appear efpecially obnoxious to its attacks ; hence the female fex are more particularly fufceptible of this affection. Its commencement is for the molt part obfeure and infidious, and its progrefs far from rapid j it lcarcely ever ariles from any obvious affignable caufe, nor can it challenge a connection with any other diforder.
Perhaps the cafe of Mrs. W. may be confidered as affording an exception to this pofition. It is admitted that fhe difcovered a difficulty of fwallowing only pofterior to her recovery from the Cynanche Maligna; but that this difeafe was the oc-? D 4 cafion cafion of the Dyfphagia is at leaft problematical, as its appearance at that juncture of time might have been cafual; and general experience, if appealed to, will be found to contradi& this inference. No age is exclufively fiiielded from its dreadful Ihafts ; however, individuals who have paffed the meridian, and are in the vale of life, become proportionally oftener the vic-r tims of it. Occafional exacerbations take place, more partir cularly during a moift atmofphere. A catarrhal indifpofition never fails to exafperate its fymptoms. To thefe two caufes co-operating, may be referred its greater urgency during the autumnal months. The genuine difeafe difclaims any neceffary combination with the ftruma, on which account we (eldom find any concomitant enlargement of the glands of the neck or throat. The occafionally impeded deglutition, the effect of local preffure frem bronchocele, is effentia'ly different in its fymptoms and phenomena from the contracted cefophagus. A fpontaneous ptyalifm, the moft confiderable during the earlier part of the day, and after eating, is an ufual attendant of this difeafe. This fymptom probably depends, not fo much upon any fpecific increafed a?tion of the falival glands (except indeed during deglutition, when they are probably ftimulated to a more copious fecretion) as upon the faliva, when fecreted, becoming accumulated in the fauces; and hence the caufe, pror bably, of the hoarfenefs fo common in the morning before expectoration has commenced. The bowels, as it might be expected, are ufually torpid. The moft charaCteriitic diagnofis of the contraCtcd throat, added to the difficulty in fvvallowing, is the regurgitation of folid, and, in very defperate cafes, of liquid ingefta. The ej eft ion does not enfue inftantly upon the food being fwallcvved, but generally a few feconds clapfe before it takes place. It may be remarked, that the longer the interval before this occurs, the more malignant proportionally is the difeafe. Anatomical diflc&ions of perlons who have died of this complaint explain the caufe of this phenomenon. In confluence of the diitenfion occafioned by the repeated remora of alimentary fubftances above the flriCtured part, a fac or pouch is ufually formed, in which the food lodges, till by its irritation a violent draining and vomiting effeCt its expulfion through the mouth or nofe, and fometimes both. There is pnly one complaint that 1 am acquainted with that is fufficiently imitative of this under consideration, as to be liable to be mistaken for the contracted cefophagus. What I now allude to, is a Ipaimodic affection of the cefophagus, frequently alio extending to the trachea, to which hyfterical females are particularly predifpofed. But the circumftance of its attack being periodical, and of only temporary duration, and of its yielding readily, * ? * *?
. ' c for the mnft part, to antifpafmodic tonics, will ferve to diflinguifh it from the difeafe which is the fubje?t of thefe remarks.
As to the fchirrous pylorus, the aliment, befides being fwallovved with the greateft facility, is reduced by digeftTon to a pultaceous ftiass before it is rejetSted by vomiting; which two circumftances will always afford marks of diftindtion between it and the contracted cefophagus.
I fhall beg leave to conclude thefe narratives and obfervations with the following inferences, clearly deducible from the foregoing premifes; Firft, It appears, I prefume, pretty fatisfadtory from what has been advanced, that the cafes of Mrs. and Mifs W. were inftances of Dyfphagia Oefophagia, occafioned by a gradual contraction of the circular order of mufcular fibres in the cefophagus, and not by an enlargement of the lymphatic glands, with which the pofterior part of this canal is ftudded, as Dr, Currie, of Liverpool, imagined, in a cafe of this kind which he relates that proved fatal. This fuppofition is, I think, admiffible, from the confideration of my method of cure, which has been adopted with compleat fuccels.
Secondly, Thefe cafes confirm the obfervations of Dr. Hunter, that ftri<?tures of the cefophagus occur chiefly near the pharynx or cardia, or both; probably from a peculiar arrangement of fibres in thefe parts performing an office fomewhat fimilar to that of fphin?ters. Thirdly, That the operation here recommended by mechanical dilatation, when cautioufly conduced, is perfectly fafe, productive of inconsiderable pain, and that of fhort duration, and apparently of lading effect; if not, it might be repeated without inconvenience.
Fourthly, And that (what renders it ftill more valuable) it is applicable in the molt inveterate ftages of this hitherto intractable difeafe ; in cases where the molt approved remedy was capable of affording only a temporary alleviation of the fymptoms.