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
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Achalasia (motility disorders) |
Esophageal cancer |
Eosinophilic esophagitis |
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Peptic stricture |
Schatzki ring (esophageal ring) |
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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
• 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.
Physical Examination
• There are no specific physical examination findings.
• Assess whether there has been significant weight loss, and assess nutritional status.
Tests for Consideration
| Clinical Entities | Medical Knowledge |
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Achalasia |
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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. |
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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. |
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Dx |
Barium swallow will demonstrate a classic “bird’s beak” appearance of the closed LES with proximal esophageal dilation. Esophageal manometry is used to definitively diagnose achalasia. Endoscopy is typically used to rule out cancer, which can cause a syndrome of “pseudoachalasia.” |
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Tx |
Medications such as calcium channel blockers (e.g., nifedipine), which relax the LES, can be used but have limited effectiveness. Botox injections via endoscopy can provide temporary relief. Pneumatic dilatation to break the sphincter muscle is another option, although perforation is a risk. A Heller myotomy (esophagocardiomyotomy) is a definitive surgical option and is effective in 90% of patients. See Cecil Essentials 36. |
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Esophageal Cancer |
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Pφ |
Esophageal cancer arises from the mucosal lining of the esophagus. It can be either a squamous cell carcinoma or adenocarcinoma. Risk factors include smoking, alcohol consumption, and obesity. In the United States, esophageal cancer is the seventh most common cancer, and adenocarcinoma is more common. Barrett esophagus is an important risk factor for developing adenocarcinoma of the esophagus. |
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Dysphagia is the most common presenting symptom. It is rapidly progressive. Weight loss is often an associated finding. Late complications include bleeding, perforation, and hoarseness caused by invasion of the recurrent laryngeal nerve. |
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Dx |
Barium studies will show strictures and intraluminal masses. Endoscopy offers direct visual inspection and the ability to perform a biopsy to make a definitive diagnosis. Endoscopic ultrasound will determine depth of invasion and staging information. |
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Tx |
Treatment depends on the stage of the cancer. Early cancers can be treated with surgical resection. There are several surgical approaches including a combined thoracic and abdominal approach (Ivor-Lewis), transhiatal esophagectomy using an abdominal and neck incision, and a “minimally invasive approach” using a laparoscopic and thoracoscopic approach combined with a neck incision. Neoadjuvant chemotherapy is often used in advanced-stage tumors before resection. When tumors are not considered resectable, chemotherapy and radiation are used. Advanced cancers are treated with palliative efforts and can include chemotherapy, radiation, and stenting procedures. See Cecil Essentials 36, 39, 57. |
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Eosinophilic Esophagitis |
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Pφ |
Eosinophilic esophagitis is becoming a more recognized and prevalent cause of dysphagia. It occurs from the infiltration of the esophageal mucosa with eosinophils that bring about inflammation of the mucosa. Some authorities consider eosinophilic esophagitis to be the result of environmental allergen exposure. |
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TP |
Patients are more commonly male. There is an association with asthma. They will typical present with intermittent dysphagia to solids. An acute food bolus impaction may be the initial presenting event. |
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Dx |
Barium study will classically show a “feline esophagus,” which has the appearance of multiple rings. Endoscopy findings include mucosal tears, furrows, rings, and whitish plaques that represent eosinophilic abscesses. Biopsy confirms a high eosinophil count. Strictures can also occur. |
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A trial of PPIs is sometimes given, as eosinophils can be seen in patients with reflux disease. Oral fluticasone is prescribed, and patients are occasionally referred to an allergist for allergy testing. Strictures can be mechanically dilated; when doing so, care must be taken to avoid perforation. See Cecil Essentials 36. |
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Peptic Stricture |
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Pφ |
Inflammation of the esophagus as a result of gastroesophageal reflux can lead to stricture formation. In untreated gastroesophageal reflux disease (GERD), up to one fourth of patients will develop strictures. |
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TP |
Patients will present with difficulty swallowing food. A history of reflux disease and heartburn is consistent with the diagnosis. |
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Dx |
Barium swallow will show intraluminal narrowing. Endoscopy offers direct visualization of the stricture. Biopsies are performed to rule out underlying malignancy. |
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Tx |
Narrow strictures are treated with dilation. This can be achieved by passing a mechanical dilator down the patient’s throat or a balloon passed through an endoscope. PPIs are recommended post procedure to prevent recurrence. See Cecil Essentials 36. |
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Schatzki’s Ring (Esophageal Ring) |
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Pφ |
A Schatzki ring is a thin ring of tissue that is formed by mucosa. It is typically located a few centimeters above the gastroesophageal junction and is usually associated with a hiatal hernia. These rings are benign. |
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TP |
Schatzki rings are usually found incidentally and infrequently cause symptoms. When symptoms occur they are intermittent. Patients usually are able pass the food bolus or regurgitate food, and continue their meal. “Steakhouse syndrome” occurs when a piece of meat becomes lodged proximal to a ring. |
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Dx |
Schatzki rings can be found on barium swallows and by upper endoscopy. |
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Tx |
If symptomatic, the ring is broken by dilation. After treatment, symptoms can occur months to years later. See Cecil Essentials 36. |
Practice-Based Learning and Improvement: Evidence-Based Medicine
Title
Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus
Authors
Herskovic A, Martz K, al-Sarraf M, et al.
Institution
Radiation Oncology Department, Oakwood Hospital, Dearborn, MI, USA
Reference
N Engl J Med 1992;326:1593–1598
Problem
Esophageal cancer is associated with a dismal 5-year survival approaching zero.
Intervention
A cisplatin-based chemotherapy regimen was added to the standard of radiation therapy.
Outcome/effect
Combined chemoradiation therapy is superior to radiation therapy alone.
Historical significance/comments
Based on the results of this trial, the standard of care for the treatment of esophageal carcinoma continues to be combined chemotherapy and radiation therapy.
Interpersonal and Communication Skills
“Doc, How Much Time Do I Have?”
You have just placed an esophageal stent in a 77-year-old man with an unresectable mid-esophageal tumor and liver metastases. Following the procedure, he asks, “Doc, how much time do you think I have?” Answering this question is not easy. It may be appropriate to determine first if the patient really wants a numerical answer; indeed, some patients do wish to know, but it is often difficult to give a specific time frame. Studies suggest that patients with advanced esophageal cancers can expect a median survival of 8 to 12 months before they succumb to a complication such as infection, bleeding, or tumor infiltration. In such circumstances it is important to provide an honest, but broad, range of time. Though you can broaden the time to extend hope, it is often wise in such a circumstance to suggest gently that the patient may want to “put his affairs in order.” Take such a cue from your patient as an opportunity to address any fears he may have, and to reassure him that every attempt will be made to help him with his disease and to provide all comfort measures that may be necessary.
Professionalism
Maintain Patient Confidentiality
A patient with esophageal cancer is accompanied by his wife to your endoscopy suite because a barium swallow has shown an esophageal mass. Your intent is to perform a biopsy. The patient has specifically asked that you not inform his wife about the biopsy results, even if the lesion appears to be cancer. Such a scenario presents a difficult dilemma for the physician. The physician-patient relationship mandates the highest degree of confidentiality. Information discovered by a physician during testing and treatment must be kept in confidence and divulged to others only with the patient’s approval. Physicians are bound to this ethical standard. As in the above scenario, a diagnosis of esophageal cancer cannot be discussed with the patient’s wife unless the patient consents (given that the patient is competent). The only circumstance in which physician-patient confidentiality can be breached is in a situation in which patients threaten to harm themselves or others.
Systems-Based Practice
A patient under your treatment for Barrett esophagus needs a follow-up endoscopy. She explains to your office manager that she was recently laid off from her job and therefore has lost her health insurance. Your office manager spends time educating her about “COBRA” insurance, the temporary continuation of a health plan for a worker and/or her family at their own cost. COBRA stands for Consolidated Omnibus Budget Reconciliation Act and refers to legislation passed by the U.S. Congress in 1986 to create a solution for workers who had lost their jobs and became ineligible for employer-sponsored health insurance benefits for themselves and/or their families. COBRA provides that workers and their families are eligible to apply for continued health insurance coverage under their existing employer-sponsored plan, except that the worker must now pay for that coverage in full, plus a surcharge to cover the cost of administering the plan. Coverage through COBRA continues for up to 18 months but may be extended up to 36 months under some circumstances.
