Edible Marijuana Use, Chest Pain, and Cough in a 53-Year-Old

Patients with esophageal cancer most often present with progressive dysphagia (initially to solids and then to liquids) caused by local obstruction.^[1,5] Dysphagia to liquids at presentation is usually indicative of advanced disease.

In addition, patients may report frequent fevers, night sweats, and significant weight loss due to dysphagia and tumor-associated cachexia. Although uncommon, odynophagia or retrosternal discomfort (pain or a burning sensation) may be the presenting symptom in some cases.^[5] Iron deficiency anemia may also be noted at initial presentation, owing to prolonged poor oral intake or gastrointestinal bleeding (acute or chronic).^[5]

Localized invasion of the tumor into the tracheobronchial system is a late complication and may lead to cough; postobstructive pneumonia, which may be recurrent; or hoarseness of voice secondary to laryngeal nerve paralysis.^[5] A past medical history of chronic GERD or Barrett esophagus is highly relevant because both conditions can lead to the development of adenocarcinoma and offer an important diagnostic clue.^[6]

Upon examination, patients may appear pale and cachectic, with a low BMI and muscle wasting. However, in this case, the patient consumed marijuana to stimulate appetite and reported only mild weight loss. Supraclavicular lymphadenopathy (such as that seen in this case) and axillary lymphadenopathy may be noted in patients with esophageal cancer.^[5] Hepatomegaly, if present, is secondary to liver metastasis and signifies unresectable disease with a poor prognosis.

For patients who present to the ED with acute-onset chest pain, it is essential to rule out immediate life-threatening causes of the pain. In this case, although the patient presented with sharp, retrosternal chest pain, a diagnosis of acute myocardial infarction was less likely given his history and physical examination findings. In addition, nitroglycerin did not provide much relief, and the troponin levels were essentially normal on presentation despite an hour of continuous chest pain. Upon repeated measurement, the troponin levels did rise slightly, but the increase can be attributed to the patient's persistent tachycardia.

This patient's history of prolonged sitting (8-12 hours per day) raised concern for deep vein thrombosis, but shortness of breath, a low oxygen saturation (≤ 88%) requiring supplemental oxygen, and an elevated D-dimer level were absent in this case, thereby ruling out acute pulmonary embolism. However, additional diagnostic workup is still necessary in cases with high clinical suspicion. Thus, ECG and chest CTA were performed in the ED, and the results were unremarkable.

Exposure to viral infections is associated with acute pericarditis. Although this patient's children had "the flu," acute pericarditis can be excluded because the patient did not describe typical pleuritic chest pain that resolves when he leans forward. On cardiovascular examination, a pericardial friction rub (highly specific and pathognomonic for acute pericarditis) was also absent. In addition, the classic ECG findings associated with acute pericarditis, which include widespread concave upward ST-segment elevation and PR-segment depression without T-wave inversions, were lacking in this case.

Perforated peptic ulcers are typically found in older patients with numerous comorbidities and regular, prolonged use of nonsteroidal anti-inflammatory drugs or corticosteroids. Such patients may present with sudden, severe epigastric pain that is accompanied by nausea and vomiting. On general examination, they may appear to be in acute distress, with tachycardia and tachypnea. Abdominal examination may reveal rigidity, guarding, and right lower quadrant tenderness (as a result of fluid tracking along the right paracolic gutter), which may progress to abdominal distention, fever, and circulatory collapse (shock). A chest radiograph may show air under the diaphragm, which was not observed in this case.

In patients with clinical suspicion of esophageal carcinoma, a barium swallow study is an acceptable initial diagnostic test.^[7] The study may reveal malignant strictures (which appear as asymmetric narrowing with irregular contours) or localized tumors (which may be polypoid, infiltrative, varicoid, or ulcerative).^[7]

Upper endoscopy with biopsy and histologic analysis remains the gold-standard diagnostic test.^[2] See this procedure performed in a different patient (Video).

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