A 69 y.o. woman with syncope...
One evening an elderly woman presents to the ED following a syncopal event. She was found on the floor of her bathroom covered in vomitus. As part of her work-up, a Chest X-ray is obtained:
What abnormalities do you see? What is your differential diagnosis and further work-up.
Scroll down for the Case Conclusion.
Final diagnosis: History of Ivor Lewis Esophagectomy with gastric pull-up
Case Conclusion: The patient had a history of esophageal cancer and had undergone an Ivor Lewis esophagectomy in 2008. This involved removal of the esophagus, resection of nodes from the chest and abdominal chains and gastric pull-up, leaving the antrum of the stomach in the abdomen. When the patient returned 8 years later with vomiting and syncope, her CXR showed the gastric pull-up which was very dilated and filled with food. Further work-up revealed innumerable mets to the bones, organs and later parietal area of the brain (A). The patient was eventually discharged on hospice after developing a bowel obstruction (B).
Learning Points: Esophageal cancer is the 8th most common cancer world wide. The incidence of adenocarcinoma of the esophagus is rising where in the past the most common cancer was squamous. [1]. The five year survival for esophageal cancer with surgical resection is 40% [2]. The initial treatment for esophageal cancer thought to be resectable is chemotherapy and radiation followed by surgery [3]. The Ivor Lewis esophagectomy is a compromise between no nodal resection proposed by Orringer and a three area node dissection proposed by Akiyama [4,5]. It is thought to produce fewer complications than the more radical procedure. Complications of the procedure include aspiration, stricture,chylothorax and leak at the anastomosis. Patients are not able to vomit but can regurgitate food.
Case Conclusion by Rosanne Naunheim
References:
1. Felay J, Shin HR, Bray F. et al. Estimates of worldwide burden of CA in 2008 GLOBOCAN 2008. International J Cancer 2010;127:2893-917.
2. Kelsen DP, Ginsberg R, Pajak T et al. Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer. 1998 NEJM 339:1979-86.
3. Van Hagen P, Hulshof J, Lanschot EW et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. 2012. NEJM. 366:222074
4. Orringer M, Marshall B, Chang A, et al. Two thousand transhiatal esophagectomies : changing trends and lessons learned. 2007. Annals of Surgery Vol 246 (3) ;363-372.
5. Akiyama H, Surumaru M, Udagawa H, Kajiama Y. Radical Lymph node dissection for cancer of the thoracic esophagus. 1998 Annals of Surgery Vol 220 (3);364-373.