CME

A man with progressive dysphagia

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Release date: June 1, 2017
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A 71-year-old man was referred to the gastroenterology department for evaluation of 9 months of progressive swallowing difficulties associated with epigastric and chest discomfort.

He was a previous smoker (17 pack-years), with a history of coronary artery disease, hypertension, and cervical spinal stenosis requiring decompressive laminectomy with a postoperative course complicated by episodes of aspiration.

DYSPHAGIA: OROPHARYNGEAL OR ESOPHAGEAL

Difficulty swallowing (dysphagia) can be caused by problems in the oropharynx or in the esophagus. Difficulty initiating a swallow can be thought of as oropharyngeal dysphagia, whereas the intermittent sensation of food stuck in the neck or chest is considered esophageal dysphagia.

Focused questioning can help differentiate oropharyngeal symptoms from esophageal symptoms. For example, difficulty clearing secretions or passing the food bolus beyond the mouth or frequent coughing spells while eating is consistent with oropharyngeal dysphagia and suggests a neurologic cause. Our patient, however, presented with a constellation of symptoms more suggestive of esophageal dysphagia.

When eliciting a history of esophageal symptoms, it is crucial to determine the progression of swallowing difficulty, as well as how it directly relates to eating solids or liquids, or both. Difficulty swallowing solid foods that has progressed over time to include liquids would raise concern for an obstruction such as a stricture, ring, or malignancy. On the other hand, abrupt onset of intermittent dysphagia to both solids and liquids would raise concern for a motility disorder of the esophagus. This patient presented with an abrupt onset of intermittent symptoms to both solids and liquids that was associated with substernal chest pain.

Once coronary disease was ruled out by cardiac biomarker testing, electrocardiography, and a pharmacologic stress test, our patient underwent upper endoscopy, which showed a normal esophageal mucosa without masses or obstruction and no evidence of peptic ulcer disease.

WHAT IS THE NEXT STEP?

When upper endoscopy is negative and cardiac causes and gastroesophageal reflux disease have been ruled out, an esophageal motility disorder should be considered.

1. After obstruction has been ruled out with upper endoscopy, which should be the next step in the investigation of esophageal dysphagia?

  • A 24-hour pH recording
  • Barium esophagography
  • Modified barium swallow
  • Computed tomography of the chest

Barium esophagography is the optimal fluoroscopic study to evaluate the esophageal phase of the swallow. This study requires the patient to swallow a thick barium solution and a 13-mm barium pill under video analysis. It is useful early in the investigation of esophageal dysphagia because it can potentially reveal areas of esophageal luminal narrowing not detected endoscopically, as well as detail the rate of esophageal emptying.1

The modified barium swallow, which is performed with the assistance of a speech pathologist, is similar but only shows the oropharynx as far as the cervical esophagus. Therefore, it would be the best fluoroscopic test to assess patients with possible aspiration or oropharyngeal dysphagia, whereas barium esophagography would be the test of choice in evaluating esophageal dysmotility or mechanical obstruction.

pH testing may be helpful in diagnosing gastroesophageal reflux disease but is less helpful in the evaluation of dysphagia.

Computed tomography of the chest may be useful to evaluate for extrinsic compression of the esophagus, but it is not the best next step in the evaluation of dysphagia.

Barium esophagography showed tertiary contractions in the distal esophagu
Figure 1. Barium esophagography showed tertiary contractions (arrows) in the distal esophagus.

Our patient underwent barium esophagography, which revealed tertiary contractions in the mid and distal esophagus with slight narrowing of the lower cervical esophagus (Figure 1). (Primary contractions are elicited when initiating a swallow that propels the food bolus through the esophagus, while secondary contractions follow in response to esophageal distention to move all remaining esophageal contents from the thoracic esophagus. Tertiary contractions are abnormal, nonpropulsive, spontaneous contractions of the esophageal body that are initiated without swallowing.2)

EOSINOPHILIC ESOPHAGITIS

Histologic study of biopsies of the mid and distal esophagus from our patient’s upper endoscopy revealed 5 eosinophils per high-power field.

2. Does this patient meet the criteria for the diagnosis of eosinophilic esophagitis?

  • Yes
  • No

No. Having eosinophils in the esophagus is not enough to diagnose eosinophilic esophagitis, as eosinophils are also common in patients with gastroesophageal reflux disease.

Eosinophilic esophagitis is defined as a chronic immune-mediated esophageal disease with histologically eosinophil-predominant inflammation (with more than 15 eosinophils per high-power field). The diagnosis is additionally based on symptoms and endoscopic appearance.3 When investigating possible eosinophilic esophagitis, it is recommended that 2 to 4 samples be obtained from at least 2 different locations in the esophagus (eg, proximal and distal), because the inflammatory changes can be patchy.

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