Presentation: Dysphagia

Question 1

What is achalasia?

Answer 1

Achalasia is the failure of oesophageal peristalsis and relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus. The LOS is contracted, and the oesophagus above is dilated.

Question 2

Who is typically affected by achalasia?

Answer 2

Achalasia typically presents in middle-age and is equally common in men and women.

Question 3

What are the clinical features of achalasia?

Answer 3

Clinical features include dysphagia of both liquids and solids, variation in severity of symptoms, heartburn, regurgitation of food, and may lead to cough or aspiration pneumonia.

Question 4

What are the potential complications of achalasia?

Answer 4

Achalasia may lead to cough, aspiration pneumonia, and malignant change in a small number of patients.

Question 5

What is the most important diagnostic test for achalasia?

Answer 5

Oesophageal manometry is considered the most important diagnostic test, showing excessive LOS tone that does not relax on swallowing.

Question 6

What does a barium swallow show in achalasia?

Answer 6

A barium swallow shows a grossly expanded oesophagus with a fluid level and a ‘bird’s beak’ appearance.

Question 7

What does a chest x-ray reveal in achalasia?

Answer 7

A chest x-ray may show a wide mediastinum and fluid level.

Question 8

What is the preferred first-line treatment for achalasia?

Answer 8

Pneumatic (balloon) dilation is increasingly the preferred first-line option due to being less invasive and having a quicker recovery time than surgery.

Question 9

When should surgical intervention be considered for achalasia?

Answer 9

Surgical intervention with a Heller cardiomyotomy should be considered if there are recurrent or persistent symptoms.

Question 10

What is the role of botulinum toxin in treating achalasia?

Answer 10

Intra-sphincteric injection of botulinum toxin is sometimes used in patients who are at high surgical risk.

Question 11

What is the role of drug therapy in achalasia treatment?

Answer 11

Drug therapy (e.g., nitrates, calcium channel blockers) has a role but is limited by side effects.

Question 12

What is dysphagia?

Answer 12

Dysphagia is difficulty swallowing. New-onset dysphagia is a red flag symptom requiring urgent endoscopy.

Question 13

What are the characteristics of dysphagia caused by oesophageal cancer?

Answer 13

Dysphagia may be associated with weight loss, anorexia, or vomiting during eating.

Past history may include Barrett’s oesophagus, GORD, excessive smoking, or alcohol use.

Question 14

What symptoms are associated with oesophagitis?

Answer 14

There may be a history of heartburn and odynophagia, but no weight loss and the patient is systemically well.

Question 15

What are the risk factors for oesophageal candidiasis?

Answer 15

There may be a history of HIV or other risk factors such as steroid inhaler use.

Question 16

What are the symptoms of achalasia?

Answer 16

Dysphagia of both liquids and solids from the start, heartburn, and regurgitation of food, which may lead to cough and aspiration pneumonia.

Question 17

What is a pharyngeal pouch?

Answer 17

A pharyngeal pouch is more common in older men and represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles.

Typical symptoms include dysphagia, regurgitation, aspiration, chronic cough, and occasionally halitosis.

Question 18

What features may be present in systemic sclerosis?

Answer 18

Other features of CREST syndrome may include calcinosis, Raynaud’s phenomenon, oesophageal dysmotility, sclerodactyly, and telangiectasia.

Question 19

What are the symptoms of myasthenia gravis related to dysphagia?

Answer 19

Dysphagia with liquids as well as solids, and other symptoms may include extraocular muscle weakness or ptosis.

Question 20

What is globus hystericus?

Answer 20

Globus hystericus may have a history of anxiety, with symptoms often intermittent and relieved by swallowing, usually painless.

The presence of pain should warrant further investigation for organic causes.

Question 21

What are the classifications of causes of dysphagia?

Answer 21

Causes of dysphagia can be classified as extrinsic, intrinsic, and neurological.

Question 22

What are examples of extrinsic causes of dysphagia?

Answer 22

Examples include mediastinal masses and cervical spondylosis.

Question 23

What are examples of intrinsic causes of dysphagia?

Answer 23

Examples include tumours, strictures, oesophageal web, and Schatzki rings.

Question 24

What are examples of neurological causes of dysphagia?

Answer 24

Examples include CVA, Parkinson’s disease, multiple sclerosis, brainstem pathology, and myasthenia gravis.

Question 25

What investigations are required for dysphagia?

Answer 25

All patients require an upper GI endoscopy unless there are compelling reasons not to perform it. A full blood count should also be performed.

Question 26

What additional studies may be required for motility disorders?

Answer 26

Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.