A Rare Case of Pancreatic Cancer Causing Secondary Achalasia

Document Type

Conference Proceeding

Publication Date

10-1-2024

Publication Title

Am J Gastroenterol

Abstract

Introduction: Secondary achalasia or pseudoachalasia is a rare esophageal motility disorder resembling idiopathic achalasia. Most pseudoachalasia cases involve neoplasia at or near the esophagogastric (EG) junction. Pancreatic cancer rarely causes pseudoachalasia. This disorder may result from circumferential obstruction of the distal esophagus or malignant infiltration destroying inhibitory neurons. We present a rare case of pseudoachalasia caused by pancreatic cancer highlights the need to consider malignancies beyond the EG junction in diagnosis. Case Description/Methods: A 77-year-old woman with a history of pancreatic adenocarcinoma presented with a 6-month history of dysphagia, abdominal pain, and a 30 lb weight loss over 3 months. Laboratory findings revealed leukocytosis, high anion gap metabolic acidosis due to starvation ketosis, and elevated liver enzymes (AST 299 U/L, ALT 384 U/L, alkaline phosphatase 942 IU/L). A CT scan of the abdomen showed progression of the pancreatic head mass, encasing vascular structures, worsening biliary duct dilation, centrally necrotic mesenteric lymph nodes, and new small ascites. An esophagogram revealed significant narrowing of the distal esophagus, gastroesophageal junction, and proximal stomach. An EGD with ERCP demonstrated type 3 achalasia and a single moderate localized malignant biliary stricture treated with biliary sphincterotomy and stent placement. The patient received 5 cycles of radiation therapy followed by resumption of chemotherapy. Due to declining health and comorbidities, further pancreatic cancer treatment was considered inappropriate. After discussion with the patient and family, they opted for hospice care, and the patient passed away 5 months later. Discussion: This case underscores the critical need to broaden the differential diagnosis when evaluating patients with unexplained dysphagia. While rare, pseudoachalasia, which has been associated with pancreatic cancer in only 4 reported cases, should be considered in such patients. When standard treatments fail to alleviate symptoms in typical achalasia cases, secondary achalasia may be suspected (see Figure 1).

Volume

119

Issue

10

First Page

S2272

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