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JAMA Surgery Clinical Challenge
December 21, 2016

Mobile Intramural Gastroesophageal Junction Mass

Author Affiliations
  • 1Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
  • 2Department of Internal Medicine, Presence Saint Joseph Hospital, Chicago, Illinois
  • 3Division of Thoracic Surgery and Pulmonary and Critical Care Medicine, Northwestern Memorial Hospital, Chicago, Illinois
JAMA Surg. Published online December 21, 2016. doi:10.1001/jamasurg.2016.4633

A healthy 43-year-old woman presented with weight loss, heartburn, and progressively worsening dysphagia to solid food. Intriguingly, the heartburn was most severe while she was sitting up but lying supine relieved the symptoms. Paradoxically, dysphagia was worse while she was reclining and partially resolved in the upright position. The physical examination was normal while laboratory workup revealed mild anemia. She was administered a trial of acid-suppression therapy for 6 weeks, which transiently alleviated heartburn but the dysphagia persisted. Subsequently, further workup with an esophagram revealed a 2.7-cm filling defect at the gastroesophageal junction, suggestive of extrinsic compression. Computed tomography demonstrated a 2.5-cm low-attenuation ovoid lesion at the gastroesophageal junction (Figure 1A). Considering a diagnosis of gastric tumor, she then underwent upper endoscopy that showed a mobile smooth-surfaced polypoid subepithelial lesion at the posterolateral wall of the gastroesophageal junction. The mass flopped back and forth into the gastroesophageal junction. Mucosal biopsies were performed, which were consistent with normal squamous mucosal epithelium. Following this, endoscopic ultrasonography was performed, which demonstrated an anechoic, loculated, subepithelial lesion located within the submucosa of the distal esophagus (Figure 1B). The endosonographic borders were well defined without invasion into the nearby structures. Manometry and 24-hour pH testing revealed preserved motility but abnormal acid exposure of the distal esophagus. Ultrasonography of the liver, gallbladder, and pancreas revealed no abnormalities.

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