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

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

Clinical Entities

Medical Knowledge

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	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.”
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.

Esophageal Cancer
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.
TP	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.
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.
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.

Eosinophilic Esophagitis
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.
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.
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.
Tx	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.

Peptic Stricture
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.
TP	Patients will present with difficulty swallowing food. A history of reflux disease and heartburn is consistent with the diagnosis.
Dx	Barium swallow will show intraluminal narrowing. Endoscopy offers direct visualization of the stricture. Biopsies are performed to rule out underlying malignancy.
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.

Schatzki’s Ring (Esophageal Ring)
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.
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.
Dx	Schatzki rings can be found on barium swallows and by upper endoscopy.
Tx	If symptomatic, the ring is broken by dilation. After treatment, symptoms can occur months to years later. See Cecil Essentials 36.