University of Florida College of Medicine-Jacksonville, Jacksonville, Florida. Question: A 71-year-old woman with a history of gastroesophageal reflux disease ...
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI A Plunging Case of Intermittent Dysphagia Rahman Nakshabendi, Andrew C. Berry, and Juan C. Munoz University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
Question: A 71-year-old woman with a history of gastroesophageal reflux disease and chronic intermittent dysphagia presented with progressively worsening dysphagia for solid foods over the past three days. The patient also complained of reflux, without weight loss, and has never had food impaction requiring bolus removal. Upon presentation, the patient denied any nausea, vomiting, abdominal pain. Laboratory results were unremarkable. Esophagogastroduodenoscopy (EGD) 6 months before admission was unremarkable. However, current endoscopy revealed a large, 4- to 5-cm subepithelial lesion in the mid esophagus at around 30 cm from the incisors. The lesion appeared smooth with normal overlying smooth tissue and no obvious ulcerations (EGD; Figure A). As the scope passed, the lesion plunged into the stomach, shown with the scope retroflexed (EGD; Figure B). CT of the chest with and without contrast confirmed the presence of a large submucosal mass 5.5 cm in width in the distal esophagus. Biopsy was performed under endoscopic ultrasonography (EUS; Figure C) with subsequent histology demonstrating a spindle cell neoplasm, combined with immunohistochemical analysis positive for CD117 (C-Kit) and negative for HMB-45. No extraesophageal masses were identified. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Acknowledgments Andrew C. Berry’s current affiliation is the Department of Medicine, University of South Alabama, Mobile, Alabama.
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 4: Gastrointestinal Stromal Tumor (GIST) Gastrointestinal stromal tumors (GIST) normally present in a vague manner, and vary depending on which region of the gastrointestinal tract in involved.1 Many present with abdominal discomfort and weight loss and, as a mass-occupying lesion, may also present as an obstruction.1 Sixty percent of tumors arise from the stomach, with primary esophageal origin quite rare (
