3 Dec - Dysphagia

Friday's case was a 60ish male who presented with insidious onset of dysphagia without odynophagia.  Swallowing solids but not liquids produced the symptoms.  The problem had been slowly pregressive over a couple months.  He had a history of CAD, atrial fibrillation and prior tobacco use.  CXR revealed an enlarged heart but no masses.  Barium swallow revealed slow transit and delayed passage of a capsule at the distal esophagus. 

The proper evaluation of dysphagia is important both to relive symptoms and to diagnose potentially lethal conditions like malignancy.  Oropharyngeal dysphagia is usually due to motor dysfunction and esophageal has a more even distribution of motor and structural causes.  In general, dysphagia to solids and liquids suggests motor causes and solids only suggests a structural lesion.

This article from Gastroenterology Clinics - Volume 32, Issue 2 (June 2003) is available through MD consult and reviews the common causes as well as a suggested diagnostic approach.  In general the first test is a barium swallow, followed by endoscopy if structural lesions or esophagitis are suggested.  If motor processes such as achalasia or esophageal spasm are suspected then manometry is the next test.

Questions about achalasia have a habit of showing up on boards.  This NEJM image case shows a fairly dramatic example.  Treatment is either surgical (heller myotomy) or medical (botox) in poor surgical candidates.  Botox does not have as durable of effect as surgery.