Severe Esophageal Dysphagia, Weight Loss, and Atrial Fibrillation: A Devastating Outcome

Abstract

Question: A 63-year-old man with a history of ischemic heart disease and atrial fibrillation presented with new-onset esophageal dysphagia to solids. One week prior he underwent coronary artery bypass surgery and left atrial radiofrequency ablation (RFA) for atrial fibrillation. He was first evaluated by a gastroenterologist from an outside facility. Barium swallow showed smooth tapering elongated stenosis of the mid esophagus with proximal esophageal dilatation (Figure A). He underwent an esophagogastroduodenoscopy (EGD) and was treated for presumed severe Candida esophagitis, even though esophageal brushings and histopathologic assessment were not diagnostic. He had no improvement in his symptoms despite taking omeprazole and fluconazole for 3 weeks. He had debilitating progressive dysphagia and malnutrition due to decreased oral intake. He lost 22 kg during the following 5 months. He was referred for a second opinion and repeat EGD showed severe esophageal stenosis, severe mucosal inflammation, and ulcerations with white exudate (Figure B, C). The stenotic esophageal segment measured 14 cm in length and 6 mm in inner diameter. Biopsies showed necroinflammatory material with granulation tissue (Figures D, E). What is the diagnosis? What is the next step in the management?