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 Table of Contents 
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 8  |  Page : 4415-4417  

A patient with dysphagia


1 Resident Physician, Department of Medicine, TMSS Medical College, Bogura, Bangladesh, Bogura
2 Professor, Department of Medicine, TMSS Medical College, Bogura, Bangladesh
3 Associate Professor, Department of Radiology and Imaging, TMSS Medical College, Bogura, Bangladesh
4 Registrar, Department of Medicine, TMSS Medical College, Bogura, Bangladesh

Date of Submission14-Mar-2020
Date of Decision25-Apr-2020
Date of Acceptance21-May-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Dr. Ahmed A Montasir
Resident Physician, Department of Medicine, TMSS Medical College, Thengamara, Bogura
Bogura
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_378_20

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  Abstract 


Mitral stenosis (MS) is the most common valvular heart disease in developing countries where rheumatic fever is common. It is also more common in women. The normal mitral orifice is 4–5 square cm in area and the symptoms do not occur until the orifice area falls to below 2.0 square cm and usually below 1.5 square cm. The orifice area decreases by 0.1–0.3 square cm per year. Rarely, the dilatation of the left atrium may cause the symptoms of dysphagia from esophageal compression. Although cardiovascular dysphagia is rare, it should be considered in the case of mitral stenosis. The etiologies of mitral stenosis can be congenital, acquired, or iatrogenic. This case report presents a patient having dysphagia due to an enlarged left atrium.

Keywords: Dilated left atrium, dysphagia, mitral stenosis


How to cite this article:
Montasir AA, Rahman M, Mondal SR, Uddin M. A patient with dysphagia. J Family Med Prim Care 2020;9:4415-7

How to cite this URL:
Montasir AA, Rahman M, Mondal SR, Uddin M. A patient with dysphagia. J Family Med Prim Care [serial online] 2020 [cited 2020 Sep 23];9:4415-7. Available from: http://www.jfmpc.com/text.asp?2020/9/8/4415/293021




  Introduction Top


The incidence and prevalence of rheumatic heart disease varies greatly. It varies among different age groups and regions of the world. The global prevalence of rheumatic heart disease is around 1 per 1,000 in children aged 5–14 years. The prevalence varies widely by region. Fewer cases were reported from the developed than from the developing countries.[1] Rheumatic heart disease usually affects the mitral valve and one of the consequences is mitral stenosis. Untreated, mitral valve stenosis can lead to complications such as pulmonary hypertension, heart failure, enlargement of different chambers of the heart causing pressure effects on surrounding structures, atrial fibrillation, and thromboembolism.[1],[2] Mostly, patients present to primary care physicians with various symptoms of mitral stenosis–related complications. Although dysphagia is not a common presenting complaint of mitral stenosis, primary care physicians should be vigilant not to miss enlarged left atrium as one of the possible causes of dysphagia.


  Case Report Top


A 40-year male presented to medicine OPD with complaints of progressively worsening dysphagia. He was suffering from dysphagia for the last six months; initially, it was only for solid but later on, for the last two months, he was facing difficulty in swallowing both solid and liquid. He did lose his weight by about five Kgs. To maintain nutrition, he used to take semisolid food. The patient was diagnosed as a case of mitral stenosis five years back; although the cardiologist advised him to undergo the operative procedure for the stenosed valve, he did not do so. For dysphagia, he took consultation several times in a primary health care setting where the diagnosis is not achieved. Clinical examination reveals a irregularly irregular pulse with a rate of 70 beats per minute, an apex beat has tapping character, and the first heart sound was loud. The clinical examinations of other systems yield no abnormality. ECG showed Irregularly irregular rhythm with an absence of definite P wave [Figure 1], posteroanterior (PA) chest radiography view demonstrated left atrial dilatation, as a prominent bulge in the left heart border [Figure 2], and the lateral view of chest X-ray showed dilated left atrium [Figure 3]. Barium swallow revealed an external indentation of the anterior esophagus [Figure 4]. Transthoracic echocardiogram (TTE) showed left atrial dimension 57 mm in the parasternal long-axis view. The left ventricular end-diastolic dimension was 41 mm. There was severe mitral stenosis. The pulmonary arterial systolic pressure was estimated to be 75 mmHg. Computed tomography (CT) of the thorax was done to exclude noncardiac causes of extrinsic esophageal compression and it confirmed a grossly dilated left atrium indenting the esophagus [Figure 5] and [Figure 6]. The patient was referred for mitral valve repair.
Figure 1: ECG showing abscence of definite P wave and irregularly irregular rhythm

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Figure 2: CXR PA view

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Figure 3: CXR Lateral view

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Figure 4: Barium swallow X ray

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Figure 5: CT chest

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Figure 6: Enlarged view of a section of CT chest

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  Discussion Top


Dysphagia is a common presenting symptom in primary care service. Dysphagia can result from several disorders. Cardiovascular dysphagia is not so common. It may be due to congenital conditions or acquired. There have been several cardiovascular conditions that are associated with dysphagia.[2],[3] Cardiovascular dysphagia was first described by Kapil in 1999. Cardiovascular structures such as double aortic arch, right aortic arch, an aberrant subclavian artery may cause dysphagia. Dilated left atrium and aortic aneurysm are the most important acquired cardiovascular causes of dysphagia.[1],[4],[5] Iatrogenic aortoesophageal fistula and postoperative dysphagia are also seen. Most cases of mitral stenosis stem from the previous episodes of rheumatic fever.[1] Most cases of rheumatic heart diseases are seen in areas of the world where rheumatic fever is common, including the Middle East, South East Asia, and South Africa. Primary care physicians practicing in these countries have to attend patients suffering from rheumatic fever and the long-term sequela of it, the rheumatic heart disease. Mitral stenosis which is the most common rheumatic heart disease inhibits the normal free flow of blood from the left atrium to the left ventricle in diastole.[1],[2],[4] The stenotic valve impedes left atrium emptying, inducing a diastolic gradient between the left atrium and the left ventricle. Prolonged elevation of the left atrial pressure causes the dilatation of left atrium and an increase in pulmonary pressure. In severe mitral stenosis, the mean pressure gradient across the mitral valve is more than 10 mm Hg. Left atrial dilatation usually occurs in moderate to severe mitral stenosis. A normal left atrium is 2.7 to 3.8 cm in diameter.[1] Giant left atrium can be caused by chronic rheumatic mitral valve disease, permanent atrial fibrillation, and chronic left ventricular failure. It is most commonly the result of chronic pressure and volume overload from rheumatic mitral valve disease.[1],[2],[6] Dilated left atrium may cause pressure effects on the surrounding structures in the middle mediastinum. The left atrium is located on the left posterior side of the heart, in front of the esophagus. The left atrial enlargement causes dysphagia by external compression of the esophagus.[1],[2],[4],[7] Dysphagia can also be caused by the extrinsic compression of the esophagus that can result from vascular anomalies, such as an aneurysmal thoracic aorta. Besides, direct compression on esophagus causing dysphagia and other suggested mechanisms for cardiovascular dysphagia include deranged peristalsis due to local ischemia of the esophageal mucosa and nerve plexus caused by the elevated external pressure; prolonged exposure of the distal esophagus to high external pressure may cause proximal esophageal muscle fatigue and dysphagia.[1],[2],[5],[6],[7] Our patient was suffering from dysphagia and had mitral stenosis. Dysphagia was also progressively worsening and due to it our patient suffered from malnutrition and weight loss. Dysphagia was caused by the extrinsic compression of the esophagus by the giant left atrium.[5],[8] Although cardiovascular dysphagia is not so common in practice, it should be suspected as a cause in patients having mitral valvular disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Braunwald E. Valvular heart disease. In: Braunwald E, editors. Heart Disease. Philadelphia, PA: W.B. Saunders; 1984. p. 1063-113.  Back to cited text no. 1
    
2.
Xie X, Xiong Q, Yu F. Dysphagia caused by giant left atrium. Eur Heart J 2020;41:1603.  Back to cited text no. 2
    
3.
Hollenberg SM. Valvular heart disease in adults: Etiologies, classification, and diagnosis. FP Essent 2017;457:11-6.  Back to cited text no. 3
    
4.
Gajanana D, Morris DL, Janzer SF, George JC, Figueredo VM. Giant left atrium causing dysphagia. Texa Heart Inst J 2016;43:469-71.  Back to cited text no. 4
    
5.
Arifputera A, Loo G, Chang P, Kojodjojo P. An unusual case of dysphonia and dysphagia. Singapore Med J 2014;55:e31-3.  Back to cited text no. 5
    
6.
Imran TF, Awtry EH. Severe mitral stenosis. N Engl J Med 2018;379:e6.  Back to cited text no. 6
    
7.
Mouawad NJ, Ahluwalia GS. Dysphagia in the aging cardiovascular patient. J Thorac Dis 2017;9:E1005-8.  Back to cited text no. 7
    
8.
Rahimtoola SH, Durairaj A, Mehra A, Nuno. Current evaluation and management of patients with mitral stenosis. Circulation 2002;106:1183-8.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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