The Third Esophageal Sphincter: A Case of Dysphagia Lusoria

A 47-year-old white male with a history of diabetes mellitis, hypertension, chronic kidney disease, and 2 years of esophageal dysphagia presented with 5 days of vomiting. His dysphagia was worse with meats and breads, and had progressed to liquids. During hospitalization, the patient had hematemesis; upper gastrointestinal endoscopy revealed external compression with arterial pulsations at the middle third of the esophagus (Figure 1 and Video 1) with LA grade D esophagitis immediately distal to this area. A contrast-enhanced computed tomography (CT) showed a right-sided aortic arch with aberrant left subclavian artery and Kommerell’s diverticulum with compression of the esophagus (Figure 2). Given his esophagitis, a pantoprazole trial was attempted, but did not elicit improvement. Esophageal manometry testing was considered, but the patient declined this procedure.