Gastric Adenocarcinoma Presenting as Pseudoachalasia: A Case Report from a Low-Resource Setting

Pseudoachalasia is an uncommon cause of dysphagia, often due to malignancy at the gastroesophageal junction (GEJ). It is crucial to distinguish idiopathic achalasia from pseudoachalasia due to tumor infiltrations of the lower esophageal sphincter.

The aim of this case is to highlight the importance of clinicopathological features that distinguish pseudoachalasia from achalasia and the most appropriate diagnostic workup as well as the management challenges in low-resource settings.

We present the case of a 76-year-old man with a 40-year smoking history presented with a one-month history of progressive dysphagia, first to solids and then to liquids, associated with epigastric discomfort, regurgitation, early satiety, and 10 kg unintentional weight loss over 4 months. Given the patient's advanced age, alarming GI symptoms, and smoking history, a malignant upper gastrointestinal pathology was highly suspected. Esophagogastroduodenoscopy (EGD) revealed an infiltrative thickened mass at the gastric cardia with reduced distensibility and irregular ulceration on retroflexion, which resulted in subtle difficulty when passing the scope across the GE junction. Computed Tomography (CT) showed circumferential irregular gastric wall thickening involving the gastric cardia, fundus, and body with regional lymphadenopathy, loss of fat plane to the pancreas concerning for invasion, and multiple small hypodense liver lesions. Histopathological examination confirmed the presence of discohesive pleomorphic cells with invasion into the lamina propria with no lymphovascular or perineural invasion was observed in the examined sections, consistent with diffuse-type gastric adenocarcinoma.

Diffuse-type gastric adenocarcinoma can present with pseudoachalasia due to GEJ involvement. In older patients with rapid-onset dysphagia and systemic red flags, prompt EGD and cross-sectional imaging are essential. Early recognition is critical but challenging in low-resource settings. Treatment of pseudoachalasia depends on the underlying cause and stage of the disease.