Abstract Body (Do not enter title and authors here): Background:
Incidental imaging findings often lead to the discovery of silent but clinically relevant conditions. An unusually distended esophagus may mimic vascular anomalies on echocardiography and raise concern for aortic pathology. This case highlights the role of multimodal imaging in differentiating vascular from non-vascular causes of mediastinal abnormalities.
Case Presentation:
A 65-year-old female with a history of hypertension, diabetes mellitus, hyperlipidemia, and prior cerebrovascular accidents with residual right leg weakness presented for evaluation of persistent dysphagia and hypertensive urgency (BP 230/103 mmHg). Her baseline BP was ~160/80 with nocturnal surges over 200/100, occasionally causing confusion. Her medications included nifedipine IR 20 mg BID and Hyzaar 100-12.5 mg daily, taken regularly. Symptoms of dysphagia had begun three weeks prior, described as food “sticking” in the chest and occasional coughing with liquids. A similar episode had occurred in Jamaica a year earlier but resolved spontaneously.
EGD revealed a Z-line irregularity 40 cm from the incisors but no strictures, diverticula, or masses. Echocardiography showed preserved ejection fraction (65%) but an anterior echodensity near the descending thoracic aorta, raising concern for a possible hematoma. A CT chest was performed, which ruled out aortic dissection, aneurysm, or hematoma but incidentally revealed a massively dilated esophagus containing air and fluid, not appreciated on EGD or echo.
Discussion:
This case illustrates how a distended esophagus can mimic aortic pathology on echocardiography, leading to diagnostic uncertainty. While echocardiography is ideal for real-time cardiac and proximal aortic evaluation, chest CT provides superior anatomical resolution and differentiation of vascular vs. non-vascular mediastinal structures. Potential etiologies of esophageal dilation include motility disorders (achalasia), chronic GERD, post-stroke dysphagia, and autonomic neuropathy in diabetes. In this patient, neurological sequelae from prior strokes and diabetic neuropathy were likely contributors.
Conclusion:
This case underscores the diagnostic value of chest CT in differentiating esophageal dilation from aortic pathology, especially when echocardiographic findings are ambiguous. It emphasizes the need for thorough evaluation of mediastinal structures in hypertensive patients presenting with atypical symptoms like dysphagia, especially with neurological comorbidities.