Drug-induced oesophageal ulceration

A number of medications, if allowed to dwell in the oesophagus, can cause severe local ulceration, pain and stricture. Factors predisposing to this phenomenon include swallowing tablets without water, particularly if taken immediately before lying down at night. Any condition that delays oesophageal transit, such as dysmotility or extrinsic compression, can result in tablet retention where it can cause oesophageal ulceration. Drugs particularly likely to cause this syndrome include tetracycline, potassium supplements, ferrous sulphate, alendronate and quinidine. The pain usually settles within a few days, but swallowed topical anaesthetic (e.g. xylocaine viscous) can provide symptomatic relief.

Gastro-oesophageal reflux disease

Reflux oesophagitis can cause odynophagia. The patient typically describes a sensation of pain or discomfort coincident with passage of the bolus through the oesophagus, sometimes combined with a sense of transient bolus hold-up. The sense of bolus arrest can dominate the symptom complex if the oesophagitis has progressed to stricture formation, but is not infrequently perceived even in the absence of a stricture. For a detailed account of investigation and management of reflux disease, refer to Chapter 1.

Causes of dysphagia

Because the physiological mechanisms controlling the different phases of swallowing differ, it is convenient to consider the aetiology of dysphagia under the categories of oral–pharyngeal and oesophageal causes, and whether the disease is structural or a motility disorder.

Oral-pharyngeal dysphagia is most commonly related to neuromuscular dysfunction, most commonly stroke (Box 2.2). Head and neck surgery and radiotherapy, for malignant disease, are also very commonly associated with oral-pharyngeal dysphagia. Other structural disorders causing oral-pharyngeal dysphagia include strictures, mucosal webs (Fig 2.1) and pharyngeal diverticulum.

Figure 2.1 Mucosal web in the cervical oesophagus seen in lateral view (left) and anteroposterior view (right).

Because gastro-oesophageal reflux disease is prevalent, peptic oesophageal strictures are a very common cause of oesophageal dysphagia (Figs 2.2 and 2.3, Box 2.3). In these cases, there is frequently a prior history of reflux symptoms. Mucosal rings, such as the Schatzki ring at the cardio-oesophageal junction, are a common cause of intermittent oesophageal dysphagia. Malignant oesophageal obstruction is usually evident on history by virtue of a short history of rapidly progressive dysphagia and significant weight loss (Fig 2.4).

Figure 2.2 Severe erosive oesophagitis (right), in this case in a patient with scleroderma oesophagus, causing odynophagia and dysphagia. Note also in this patient the abnormal pooling of saliva seen endoscopically (left) indicative of poor oesophageal clearance due to aperistalsis secondary to scleroderma oesophagus. This can be a useful, endoscopic indicator of an underlying motility disorder.

Figure 2.3 Barium radiograph showing (arrows) a distal oesophageal stricture in a patient with long-standing severe reflux disease.

Figure 2.4 Endoscopic appearance of an oesophageal cancer in a patient with a short history of progressive dysphagia.

Approach to the assessment of the patient with dysphagia

It cannot be overemphasised how important the clinical history is in assessing dysphagia. A history alone should yield the likely site and nature of the problem in 80% of patients. Investigational priorities will hinge on the history. The history and examination of the patient with dysphagia should address these four fundamental questions: