Esophageal Dysphagia (Case 21)

Published on 24/06/2015 by admin

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Last modified 24/06/2015

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Esophageal Dysphagia (Case 21)

Benjamin Ngo MD and John Abramson MD

Case: A 50-year-old man is encouraged by his wife to present for an evaluation of difficulty swallowing solid food that has progressively worsened over several months. He complains of occasional heartburn and is otherwise without significant medical problems. He has had an associated 15-lb weight loss.

Differential Diagnosis

Achalasia (motility disorders)

Esophageal cancer

Eosinophilic esophagitis

Peptic stricture

Schatzki ring (esophageal ring)

 

Speaking Intelligently

We consider dysphagia and weight loss in this patient as “red flags” that should cause concern. Additional diagnostic testing is necessary. Certainly there are many causes of difficulty swallowing, but in this situation dysphagia and weight loss indicate that esophageal carcinoma must first be considered. This is not a patient with nonspecific upper GI symptoms who should simply be placed on a proton pump inhibitor (PPI) and followed.

PATIENT CARE

Clinical Thinking

• Determine the onset and acuity of symptoms. Persistent dysphagia with the inability to swallow secretions suggests a foreign body or food bolus impaction. This represents a GI emergency that must be dealt with expeditiously.

• Establish if the swallowing problem is with solids, liquids, or both.

• Determine associated symptoms.

History

• A focused history should include timing of onset and duration of symptoms.

• Characterize whether symptoms are intermittent or progressive. Does the swallowing difficulty occur with solids, liquids, or both?

• Inquire about symptoms of heartburn, current or past use of over-the-counter antacids, and use of alcohol and tobacco.

Physical Examination

• There are no specific physical examination findings.

• Assess whether there has been significant weight loss, and assess nutritional status.

• Whenever we entertain a diagnosis of esophageal carcinoma, we always palpate for supraclavicular adenopathy.

Tests for Consideration

• Barium swallow can define many causes of dysphagia.

$85

• Upper endoscopy has the ability to both define and potentially treat dysphagia (i.e., a peptic stricture can be dilated at the time of diagnosis)

$600

• Plain chest radiographs may show a mediastinal mass compressing the esophagus.

$45

• Esophageal manometry is used for the diagnosis of motility disorders. As a bolus of food or liquid passes down the esophagus, abnormal pressure wave progressions will be recorded in diseased states.

$285

• Endoscopic ultrasound, when appropriate, can stage esophageal and periesophageal masses, and offer prognostic information to help guide future therapeutic plans.

$885
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Achalasia

Pφ

Achalasia results from the inability of the lower esophageal sphincter (LES) to relax, as a result of a defect in the inhibitory motor neurons. The cause of primary achalasia is unknown. It affects about 1 in 100,000 persons. Chagas disease is an uncommon form of secondary achalasia and is acquired via infection with Trypanosoma cruzi.

TP

Patients complain at first of progressive dysphagia to solids, and then to both solids and liquids. Regurgitation can occur (usually at night) in the reclining or recumbent position. Chest pain is frequently a symptom.

Dx

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