Pseudoachalasia From Gastric Cancer

A 59-year-old woman was referred from another hospital for esophageal balloon dilatation, with the impression of idiopathic achalasia. She developed progressive dysphagia of 3-month duration associated with weight loss of about 5 kg. She did not have abdominal pain, odynophagia, tarry stool, or hematemesis. Her previous medical history was unremarkable. She denied tobacco use or alcohol consumption. Physical examination centered on abdominal findings of mild tenderness at the epigastric area. There was no palpable lymphadenopathy. Laboratory examinations including hemogram and serum tumor markers (carcinoembryonic antigen, 2.65 ng/mL; CA19-9, 18.78 U/mL) were within normal limits.

Barium esophagogram (Figure A) showed a dilated distal esophagus with “bird's beak” tapering. Upper gastrointestinal endoscopy revealed a puckered tight gastroesophageal junction with smooth mucosal surface (Figure B). No mass lesions were discernible. Relatively hypertrophic folds were noted at the upper and middle body of the stomach. Endoscopic biopsy at the enlarged folds revealed adenocarcinoma of diffuse type. She underwent total gastrectomy with distal esophagectomy uneventfully. Histopathology showed scattered clusters of cancer cells infiltrating all layers of the gastric wall, with myenteric and serosal involvement (Figure C, arrow).

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Infiltrative gastric adenocarcinoma might mimic idiopathic achalasia when the infiltrating cancer cells involve the myenteric neural plexus at the lower esophagus, impairing relaxation of the lower esophageal sphincter. Pseudoachalasia caused by infiltrative cancers usually cannot be distinguished from idiopathic achalasia by routine endoscopy, radiography, or manometry.1 Computed tomography might be helpful in that the esophageal wall thickening is usually marked (>10 mm) and/or asymmetric in the case of pseudoachalasia.2 In difficult patients with negative endoscopic biopsies, endoscopic ultrasound might reveal the infiltrating tumors invading through the esophageal wall, and endoscopic ultrasound–guided fine-needle aspiration might secure a tissue diagnosis.3 Clinical features suggestive of pseudoachalasia include a short duration of symptoms (less than 6 months), old age (older than 50 years), and rapid body weight loss.1 All of these clinical features are compatible with our patient, who illustrates the importance of a high index of suspicion for the correct diagnosis.