Correspondence
An Unusual Cause of Dysphagia
N Engl J Med 1997; 336:1612-1613May 29, 1997
- Article
To the Editor:
Dysphagia has many causes, including mechanical obstruction and neurologic disorders. Foreign bodies occasionally cause dysphagia, especially in the elderly and in children.1 Usually, however, dysphagia does not improve without treatment of the underlying condition. I recently cared for an elderly woman with a peculiar cause of dysphagia that was promptly relieved by an episode of emesis.
A previously healthy elderly woman admitted to the hospital because of anemia was found to have colonic carcinoma. She underwent an uneventful hemicolectomy with a primary anastomosis. A nasogastric tube was inserted after surgery and removed 48 hours later. Bowel function returned after five days. Because of poor oral intake, however, a subclavian venous catheter was inserted for parenteral nutrition. While the patient was in the supine position during the procedure, she reported having difficulty swallowing. Several minutes after the procedure, the patient had an episode of emesis and produced a large organized blood clot (Figure 1Figure 1
Organized Blood Clot Produced during an Episode of Emesis in an Elderly Woman with Dysphagia after Nasogastric Intubation.). After vomiting up the clot, she noted that her swallowing was normal. The patient stated that over the previous two days, it had felt as if her “food were sticking” in her midsternal area, and this was why she had not been eating well. There was no hematemesis, melena, or abdominal pain. She took no nonsteroidal drugs and had no history of ulcer disease. A chest radiograph was normal, and her hematocrit was 30 percent — unchanged from the value obtained several days before the episode. An esophagogastroduodenoscopy showed severe erosive esophagitis with a small denuded area in the midesophagus, which was assumed to be the site of the dislodged clot. A small bleeding arteriole was injected with epinephrine. The stomach and duodenum were normal. The patient was treated with omeprazole and had an uneventful recovery, without further dysphagia or evidence of blood loss.This patient had severe esophagitis related to gastric acid reflux that was possibly associated with the nasogastric tube. She had no clinical evidence of gastrointestinal tract bleeding before or after vomiting up the blood clot. The fact that the clot was organized suggests that a local area of bleeding had occurred several days before, possibly in association with trauma from the nasogastric tube. Her dysphagia promptly disappeared after the clot was expelled, suggesting that it was the cause of her symptoms.
1 ReferencesMark A. Marinella, M.D.
Miami Valley Hospital, Dayton, OH 45409
