Esophageal dysphagia

Did You Know?

• Patients with esophageal stricture may have symptoms relating to the underlying cause, such as chronic heartburn from GERD.
• Consultations with a speech therapist and registered dietitian nutritionist are needed for dietary modifications such as thickened fluids.

Causes

Dysphagia to both solids and liquids suggests a motility problem, while initial dysphagia to solids progressing to liquids indicates mechanical obstruction. Intermittent motility dysphagia may be due to diffuse esophageal spasm or nonspecific esophageal motility disorder. Progressive motility dysphagia includes scleroderma or achalasia. Intermittent mechanical dysphagia is likely an esophageal ring, and progressive mechanical dysphagia is often peptic stricture or esophageal cancer.

Differential diagnosis

Esophageal stricture is usually a complication of acid reflux, most commonly from GERD, and presents as progressive mechanical dysphagia. Other causes include Zollinger–Ellison syndrome, nasogastric tube trauma, scleroderma, infectious esophagitis, chemical irritants, pill irritation, and radiation. Stricture diameter below 12 mm always causes dysphagia; above 30 mm does not. Esophageal cancer also causes progressive mechanical dysphagia, with rapidly progressive dysphagia, weight loss over 10 kg, and anorexia. Adenocarcinoma is most prevalent in the US and linked to chronic GERD with Barrett's esophagus; squamous cell carcinoma is more common in Asia and associated with tobacco and alcohol. Esophageal rings (Schatzki rings) are mucosal rings at the squamo-columnar junction causing intermittent mechanical dysphagia; multiple rings may suggest eosinophilic esophagitis.

Diagnostic tools

A patient with dysphagia should undergo upper endoscopy (EGD). Biopsies are taken even if the EGD appears normal. If a proximal lesion is suspected—such as from prior surgery, radiation, achalasia, or Zenker's diverticulum—a barium swallow may be performed before endoscopy to reduce perforation risk. If achalasia is suspected, endoscopy excludes malignancy, then manometry confirms. Normal endoscopy followed by normal manometry leads to a diagnosis of functional dysphagia.