IMAGE OF THE MONTH Esophageal Strictures: An Unusual Presentation of a Common Disorder Sagar R. Shroff, Sunil Dacha, and Heba Iskandar Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
54-year-old woman with a history of cutaneous sarcoidosis presented with 3 years of progressive dysphagia, marked by solids and liquids “getting hung up” in her chest without any choking or gagging sensation. She suffered a resultant 40-pound weight loss in the preceding 6 months. Her physical examination was unremarkable. Esophagogastroduodenoscopy showed a mildly erythematous esophageal stricture (Figure A) at 24 cm from the incisors measuring 8 mm in diameter and 2 cm in length that could not be traversed with an adult gastroscope. An ultrathin endoscope was able to traverse the proximal esophageal stricture and showed a similar esophageal stricture at 37 cm measuring 10 mm in diameter and 2 cm in length. The proximal esophageal stricture was dilated with a through-the-scope balloon to 10 mm. Biopsy specimens obtained from proximal and distal esophageal strictures showed normal squamous esophageal epithelium. A barium swallow (Figure B) subsequently was obtained, which showed proximal and distal esophageal strictures. A repeat esophagogastroduodenoscopy showed both strictures, which were dilated, and repeat biopsy specimens were obtained from both strictures. Histopathology from the proximal stricture showed a crushed epithelioid, noncaseating, non-necrotizing granuloma consistent with sarcoidosis, establishing the diagnosis of esophageal sarcoidosis (Figure C). The patient was started
A
on a prolonged prednisone taper with improvement in her dysphagia. The patient then was bridged from prednisone to methotrexate with sustained response 6 months later. Sarcoidosis is an inflammatory, granulomatous, multisystem disorder of unclear etiology and commonly involves the lungs and lymphatics.1 Sarcoidosis rarely affects the gastrointestinal tract (5%–10%), but less than 1% of patients have clinical manifestations.2,3 The stomach is the most commonly involved organ and often presents with epigastric pain.4 Esophageal sarcoidosis was first reported by Kerley5 in 1948 and is extremely rare with only 24 cases reported to date.6 Typically, esophageal sarcoidosis patients present with dysphagia (91.3%) and less commonly with weight loss (21.7%), odynophagia, anemia, abdominal pain, or hoarseness of voice (
54-year-old woman with a history of cutaneous sarcoidosis presented with 3 years of progressive dysphagia, marked by solids and liquids “getting hung up” in her chest without any choking or gagging sensation. She suffered a resultant 40-pound weight loss in the preceding 6 months. Her physical examination was unremarkable. Esophagogastroduodenoscopy showed a mildly erythematous esophageal stricture (Figure A) at 24 cm from the incisors measuring 8 mm in diameter and 2 cm in length that could not be traversed with an adult gastroscope. An ultrathin endoscope was able to traverse the proximal esophageal stricture and showed a similar esophageal stricture at 37 cm measuring 10 mm in diameter and 2 cm in length. The proximal esophageal stricture was dilated with a through-the-scope balloon to 10 mm. Biopsy specimens obtained from proximal and distal esophageal strictures showed normal squamous esophageal epithelium. A barium swallow (Figure B) subsequently was obtained, which showed proximal and distal esophageal strictures. A repeat esophagogastroduodenoscopy showed both strictures, which were dilated, and repeat biopsy specimens were obtained from both strictures. Histopathology from the proximal stricture showed a crushed epithelioid, noncaseating, non-necrotizing granuloma consistent with sarcoidosis, establishing the diagnosis of esophageal sarcoidosis (Figure C). The patient was started
A
on a prolonged prednisone taper with improvement in her dysphagia. The patient then was bridged from prednisone to methotrexate with sustained response 6 months later. Sarcoidosis is an inflammatory, granulomatous, multisystem disorder of unclear etiology and commonly involves the lungs and lymphatics.1 Sarcoidosis rarely affects the gastrointestinal tract (5%–10%), but less than 1% of patients have clinical manifestations.2,3 The stomach is the most commonly involved organ and often presents with epigastric pain.4 Esophageal sarcoidosis was first reported by Kerley5 in 1948 and is extremely rare with only 24 cases reported to date.6 Typically, esophageal sarcoidosis patients present with dysphagia (91.3%) and less commonly with weight loss (21.7%), odynophagia, anemia, abdominal pain, or hoarseness of voice (
