A 35-year-old woman comes to the office due to solid food dysphagia for the past several months. The patient has a sensation of food getting stuck in the mid-thorax, but has no pain or reflux. She also has palpitations and dyspnea on exertion. The patient immigrated to the United States from India 1 year ago, and was treated in her home country for rheumatic heart disease. Barium esophagram demonstrates extrinsic compression on the mid-esophagus. Enlargement of which of the following is most likely causing this patient's dysphagia?

Question

A 35-year-old woman comes to the office due to solid food dysphagia for the past several months.  The patient has a sensation of food getting stuck in the mid-thorax, but has no pain or reflux.  She also has palpitations and dyspnea on exertion.  The patient immigrated to the United States from India 1 year ago, and was treated in her home country for rheumatic heart disease.  Barium esophagram demonstrates extrinsic compression on the mid-esophagus.  Enlargement of which of the following is most likely causing this patient's dysphagia?

Quizplus · Accepted Answer

11ec160b_355b_4da8_9249_979961939bf9_MD0001_00 This patient with a history of rheumatic heart disease has likely developed mitral stenosis/regurgitation (eg, palpitations, exertional dyspnea), leading to left atrial enlargement and extrinsic compression of the esophagus (eg, solid food dysphagia). The posterior surface of the heart is mostly formed by the left atrium, which lies directly over the esophagus. Longstanding mitral stenosis/regurgitation can lead to progressive left atrial enlargement, further displacing the left atrium posteriorly and causing external compression of the mid-esophagus with dysphagia (cardiovascular dysphagia). On rare occasions, left atrial enlargement can also cause compression of the left recurrent laryngeal nerve, leading to voice hoarseness and chronic cough. (Choice B) The left ventricle makes up most of the left surface of the heart, which abuts the left lung. (Choice C) The pulmonary artery emerges from the right ventricle and branches into the right and left pulmonary arteries below the aortic arch. (Choices D and E) The anterior (sternocostal) surface of the heart is mostly formed by the right atrium superiorly and right ventricle inferiorly. Blood from the coronary sinus and inferior and superior venae cavae drain into the right atrium, which then drains blood into the right ventricle through the tricuspid valve. Educational objective: Cardiovascular dysphagia can result from external compression of the esophagus by a dilated and posteriorly displaced left atrium in patients with rheumatic heart disease and mitral stenosis/regurgitation. __________ References: An unusual case of dysphonia and dysphagia. (http://www.ncbi.nlm.nih.gov/pubmed/24154555)

A 35-Year-Old Woman Comes to the Office Due to Solid