COTW: Progressive Dysphagia

A 31 year old man presents with progressive dysphagia. It's a story we've heard many times.

"Dysphagia" is a pretty specific medical term, meaning the sensation of food getting stuck somewhere along it's path down to your stomach. This young man had several months of progressive dysphagia, first with solids, then with liquids, accompanied by weight loss. He had a worrisome barium swallow from an outside hospital, and was referred here. We admitted him to be rehydrated and then to get a scope of his esophagus and stomach, but we already knew the diagnosis: Esophageal cancer.

Some of the medical types are currently thinking that I'm rushing it. "Whoa, I mean maybe if he was 65, with a history of chronic reflux, but surely that's not the most likely thing in a 31 year old." I would have thought that as well, but as it turns out, according to the NIH, Tenwek Hospital reports the highest rates of esophageal cancer in young people anywhere. Ever. In the world. Right here.

This is an incredible tragedy for the people we serve, especially as they almost always present so late that there are no curative options left to them. Our endoscopy department does a phenomenal amount of stenting open esophagi (esophaguses?) blocked by cancer, thus giving people the ability to eat again, and often adding a year or 2 to their lives, but very few people have the option of curative surgery. A few months ago, I sent home a 17 year old young man with unresectable esophageal cancer. That's right. I sent him home from the Pediatric ward to follow-up with our hospice program.

Why? Theories abound, and research is being done. Some genetics, some pesticide toxins, some relation to the hot chai that people love drinking. No one is entirely sure, but there is a ton.

So, yes, even a 31 year old with that classic story is a cinch of a diagnosis. So, they took him to endoscopy, prepared to offer another grim diagnosis and another hospice referral. This is what they found:

His esophagus was blocked, not by cancer, but by a plastic bag, a metal belt clip, and part of a denim pocket. The offending items were removed to find a totally normal esophagus underneath. How did these strange items get down to a location where they could so mimic a lethal cancer? The answer is unclear, but it sounds like the guy had been deteriorating slowly under a bad habit of illegal drugs (which is actually quite rare around here). We check the above items for evidence of such material, but nothing.

So, good news for this guy, though he still has some significant challenges ahead.