Dysphagia in a 30-year-old woman: too old for a congenital abnormality?

A 30-year-old woman presented to the acute medical take with nausea and vomiting of 48 hours' duration. Clinical examination showed no evidence of bowel obstruction. X-rays showed no abnormalities and blood tests were unremarkable. A gastroenterology opinion was sought. A closer probing of the history revealed that the vomiting consisted of regurgitation of completely undigested food contents shortly after eating. As an infant she had been diagnosed with a ‘narrow’ oesophagus, but had been told by paediatricians that she would ‘grow out of it’. She was of short stature, and on closer questioning revealed that she had always found eating difficult and had a poor appetite. The possibility of partial oesophageal atresia was raised. A gastroscopy was performed which revealed almost complete obstruction of the oesophagus at 35 cm. On barium swallow a thin string-like 4 cm passage into the stomach was evident, enough to allow the passage of fluids (Figures 1–3). A computed tomography scan was performed to further delineate the anatomy and to exclude a mass lesion associated with the stricture. Owing to the severity of the stenosis, it was felt that dilatation would only provide temporary relief and could be potentially dangerous, with a high risk of perforation. A surgical review was requested and it was decided that a Merendino jejunal transposition may be required to allow effective swallowing. The patient was consented for this elective procedure, and she was fed on a liquid diet of build-up products for 3 weeks. Surgery went ahead as planned. However, during the operation it was decided that the changes were not as severe as previously felt and that a simple myotomy would provide adequate relief, with the option to proceed to more aggressive surgery at a later date if needed. It was probable that a degree of the narrowing seen on imaging was caused by inflammation from eating solid foods, and that this had improved on the liquid diet. The postoperative period was complicated by an anastomotic leak. However, the patient recovered quickly from this and was discharged home shortly afterwards. In the 3 months post surgery she continued to improve, and she is now able to eat a normal diet without difficulty.