General oto esophageal dysphagia

Question 1

In a patient with dysphagia, how can you differentiate oropharyngeal from esophageal dysphagia based on symptoms?

Answer 1

● Esophageal dysphagia: Food gets stuck after the swallow
is completed because of structural or neuromuscular
pathology; the problem is in the esophageal body or
lower esophageal sphincter.
● Oropharyngeal dysphagia: Difficult to complete swallow;
disorders involve the oropharynx, hypopharynx, and
upper esophageal sphincter.

Question 2

How does the differential diagnosis change if a
patient with esophageal dysphagia complains of symptoms with solids only versus both solids and
liquids?

Answer 2

Mechanical obstruction usually causes difficulty with solids (but it may progress to involve liquids later on). Motility disorders commonly result in concurrent solid and liquid dysphagia.

Question 3

What are the most common diagnoses in a patient

with solid-food esophageal dysphagia?

Answer 3

● Esophageal ring (intermittent)
● Peptic stricture (progressive)
● Malignancy (progressive)

Question 4

What is the most common cause of acute

esophageal dysphagia?

Answer 4

Food impaction (meat); results in saliva expectoration

Question 5

What disease process is characterized by decreased or absent lower esophageal sphincter relaxation and decreased or absent esophageal
peristalsis?

Answer 5

Achalasia (Greek: “does not relax”)

Question 6

Eagle syndrome is associated with what anatomical abnormality?

Answer 6

Elongated styloid process (about > 3 cm) and/or ossification

or calcification of part or all the stylohyoid ligament. This syndrome was described in 1937 by Dr. Wyatt Eagle.

Question 7

Dysphagia lusoria is associated with what anatomical anomaly?

Answer 7

Aberrant right subclavian artery

Question 8

What histopathologic findings support the diagnosis of achalasia?

Answer 8

Decrease in total ganglion cells within the myenteric plexus,
the presence of T cell, eosinophil, and mast cell infiltration,
and increased neural fibrosis

Question 9

What is the general age group most commonly

affected by achalasia?

Answer 9

20 to 60 years

Question 10

What are the primary complaints associated with loss of lower esophageal sphincter relaxation and
esophageal aperistalsis (achalasia)?

Answer 10

Solid and liquid dysphagia, weight loss, chronic cough,

chest pain, hiccups, regurgitation, heartburn, and globus

Question 11

What three associations are often included in
triple A syndrome (Allgrove syndrome), which is
most commonly found in children?

Answer 11

● Achalasia
● Adrenal insufficiency
● Alacrima

Question 12

What infectious disease can lead to clinical

manifestations of achalasia?

Answer 12

Chagas disease

Question 13

What management strategy can be used to reverse or stop the progression of achalasia?

Answer 13

None. The goal of management is to decrease lower

esophageal sphincter tone and manage reflux.

Question 14

What is first-line therapy for patients with severe

achalasia?

Answer 14

Surgical dilation or myotomy unless the patient is a poor

operative candidate

Question 15

What medical options are available for patients

with achalasia?

Answer 15

Nitrates and calcium channel blockers with the goal of

decreasing lower esophageal sphincter tone

Question 16

What surgical interventions are available for

achalasia?

Answer 16

Good operative candidates may undergo pneumatic dilation or myotomy. Poor operative candidates may undergo dilation with a bougie or botulinum toxin injection.

Question 17

What pathogen is associated with Chagas disease?

Answer 17

Parasite Trypanosoma cruzi

Question 18

What is the vector for Trypanosoma cruzi?

Answer 18

Reduviid bugs

Question 19

Describe the esophageal manifestations of Chagas disease?

Answer 19

● Megaesophagus with dilation and muscular hypertrophy
● Reduction in the number of neurons in the myenteric
plexus

Question 20

What is the most common condition associated

with chronic Chagas disease?

Answer 20

● Cardiomyopathy
● Arrhythmias
● Conduction blocks

Question 21

What are the clinical manifestations of scleroderma?

Answer 21

Skin tightening, hyperpigmentation, and hypopigmentation
of skin, sclerodactyly, Raynaud phenomenon, GERD,
arthralgias, myalgias, Sicca syndrome, and dysphagia

Question 22

How common is esophageal involvement in

patients with scleroderma?

Answer 22

90%; 50% experience significant symptoms

Question 23

The progressive fibrosis and atrophy within the
smooth muscle of the esophagus associated with
scleroderma manifest with what classic finding on
esophageal manometry and barium esophagram?

Answer 23

● Manometry: Progressive loss of esophageal body peristalsis in distal two-thirds and decreased lower esophageal sphincter pressure
● Barium esophagram: Dilated esophagus, patulous gas-
troesophageal (GE) junction, and uninhibited reflux
events into the distal esophagus

Question 24

What are common complications noted in patients

with scleroderma and GERD?

Answer 24

Barrett esophagus, esophagitis, and strictures

Question 25

What laboratory test is most sensitive and specific

for dermatomyositis?

Answer 25

Creatine kinase

Question 26

How is dermatomyositis commonly treated?

Answer 26

Systemic steroid therapy and potentially immunosuppres-
sive and cytotoxic therapy, including methotrexate, aza-
thioprine, and cyclophosphamide

Question 27

Describe the potential head and neck manifestations of dermatomyositis.

Answer 27

Heliotrope discoloration of upper eyelids, malar rash,

dysphonia, dysphagia, scaly scalp, and hair loss

Question 28

What part of the aerodigestive tract is affected by

polymyositis?

Answer 28

Hypopharynx and upper third of the esophagus

Question 29

What is the cause of diffuse esophageal spasm?

Answer 29

Neural and muscular defects triggered by reflux events,
stress, extreme temperature variability in food or drink,
carbonation, or particular smells

Question 30

What symptoms are associated with diffuse

esophageal spasm?

Answer 30

Intermittent esophageal dysphagia, noncardiac chest pain,

reflux/heartburn

Question 31

What are the classic esophageal manometric
findings in patients with diffuse esophageal
spasms?

Answer 31

Two or more uncoordinated contractions during 10 consecutive swallows, aperistalsis in more than 30% of wet swallows, and a fifth of contractions being simultaneous