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JAMA Clinical Challenge

Severe Intractable Postprandial Chest Pain

Image of Barium swallow radiograph in patient

Conall Fitzgerald, MB BCh BAO
Orla Mc Cormack, MD, FRCSI
John V. Reynolds, MD, FRCSI
A 44-year-old man with a 3-year history of postprandial chest pain and odynophagia presents with a severe exacerbation of symptoms over 2 months and a weight loss of 8.1 kg. His history included lumbar spine surgery and chronic back pain leading to continued requirement for opiate analgesia. Endoscopy revealed food stasis throughout the esophagus, large diverticula in the lower esophagus, no resistance at the lower esophageal sphincter, and extensive candidiasis. A barium swallow was diagnostic (Figure). Esophageal manometry demonstrated 100% hypertensive propagated pressure waves in the distal esophagus, with a mean esophageal pressure of 335 mm Hg, a maximum pressure of 701 mm Hg, and normal relaxation of the lower esophageal sphincter. The patient was treated with antifungal therapy and received a 1-month course of calcium channel antagonists, but symptoms were unchanged and weight loss progressed.

See the full article for an explanation and discussion.

Author Affiliations: Drs Reynolds (reynoljv@tcd.ie), Fitzgerald and Mc Cormack are affiliated with the National Center for Esophageal and Gastric Surgery, St James’s Hospital, and Trinity College, Dublin, Ireland.