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The assessment of symptomatology is of crucial importance in the patient with esophageal disease and there are almost no physical signs of esophageal disease, so there’s much we can find on examination and we really are relying very heavily on symptoms. Fortunately there are not very many esophageal symptoms and they are reasonably helpful in diagnosing achalasia, Schatzki’s ring and scleroderma.
Clearly, dysphasia is the most common symptom and is the one that is the most likely to bring the patient rushing to your office. Odynophagia or discomfort or pain on swallowing is also a highly helpful symptom, as we will hear later.
As I mentioned, dysphagia is certainly the most distressing symptom and probably the one that demands the most immediate attention. It can be an acute emergency. Again, I emphasize the importance of differentiating dysphagia and odynophagia. Patients not so much confuse these by they forget to tell you about the extra pain that occurs on swallowing. eliciting the specific symptom of odynophagia is important because it tells you a lot about what’s going on. Odynophagia is virtually pathognomonic for esophagitis. And whether it be reflux esophagitis or in particular the esophagitis that occurs with Candida, Herpes simplex and CMV and other opportunistic infections.
Now there are several things you can ask the patient which may help in the differential diagnosis. Clearly the level at which the dysphasia is occurring is important. Is it at the oropharynx? What is the natural history? Is it episodic like you would see with a _disorder, or is it progressive as you would see with carcinoma or peptic stricture. What induces the dysphagia? Does it occur only with solids?
This is a guide towards the differential diagnosis of dysphagia, describing four fairly common causes. In the patient with cancer, typically the dysphagia would be rapidly progressive, would begin with solids and later progress to liquids and will often be associated, needless to say, with weight loss. In the patient with a peptic stricture, the history will usually be more slowly progressive, would be predominantly with solids and may be associated with reflux, although surprisingly quite a few patients who present with a peptic stricture, which is clearly due to reflux, do not give a clear history of reflux symptoms. Now the Schatzki’s ring is a very specific disorder.
I want to spend quite a bit of time talking about reflux disease. I think there is a general consensus that reflux is increasing in prevalence. There have been a lot of advances in our evaluation and management of reflux disease and also a considerable expansion of the spectrum of reflux. We know now that reflux is indeed a true spectrum which extends from reflux which is truly physisological and occurs in all of us on a daily basis, to the patient at the other extreme with complicated esophagitis; ulceration, hemorrhage, stricture, Barrett’s and of course, the most feared complication, adenocarcinoma arising of Barrett’s esophagus. In between are the majority of the patients we see. Those who have esophagitis or those who have symptoms but no esophagitis. Now another big issue in reflux disease, which continues to undergo evolution, is Barrett’s esophagus and we have some new information in Barrett’s which I’ve summarized on this slide.
Peptic strictures; another complication of reflux disease. Again here I think things have changed dramatically. These patients tend to be older, for reasons that we don’t understand. Now I want to spend a little bit of time talking about esophageal motility disorders. I suggest at the outset that these are relatively uncommon, and that’s true, but I think there are a few points that are of clinical importance. The most important one is achalasia. Achalasia is not common but it is not rare. The important part about achalasia is that we can treat it and treat it very effectively, so it’s important not to miss it. A diffuse spasm is extremely rare and scleroderma is relatively common and commonly affects the esophagus but leads to reflux rather than spasm or pain.
Now achalasia is a clearly defined manometric disorder. You’ve got absence of peristalsis in the esophageal body and incomplete or absence of relaxation in the lower esophageal sphincter, leading to a functional obstruction. The ileus pressure can be increased or the intraesophageal pressure can be increased, but these are not necessary.
Achalasia: there are a number of therapeutic advances here. We pretty well know the cause of this here is due to lack of inhibitory innervation to the lower esophagus sphincter. There are three therapeutic options - there are actually four but one of them is pretty useless, and that’s medical therapy with nitrates or calcium channel blockers.
I mentioned at the outset that there were two categories of dysphagia. The esophageal dysphagia, which may lead to cancer, stricture or these motility disorders that I’ve just described. But I also mentioned oropharyngeal dysphasia and I want to come back to that, because it is quite different in its approach. As I hope I’ve emphasized to you, dysphagia in the esophageal body is usually due to diseases that are intrinsic to the esophagus, whether it’s a cancer, peptic stricture, or achalasia. On the other hand, transfer or oropharyngeal dysphasia is usually due to disease.