A man with progressive dysphagia
WHAT DOES THE PATIENT HAVE?
3. What is the likely cause of this patient’s dysphagia?
- Eosinophilic esophagitis
- Achalasia
- Esophageal spasm
- Extrinsic compression
- Esophageal malignancy
Eosinophilic esophagitis causes characteristic symptoms that include difficulty swallowing, chest pain that does not respond to antisecretory therapy, and regurgitation of undigested food. As we discussed above, this patient has only 5 eosinophils per high-power field and does not meet the histologic criteria for eosinophilic esophagitis.
Achalasia has a characteristic “bird’s beak” appearance on esophagography that results from distal tapering of the esophagus to the gastroesophageal junction,1 and this is not apparent on our patient’s study.
Review of this patient’s esophagogram also does not reveal any extrinsic compression, esophageal malignancy, or distal tapering suggesting achalasia. In light of the abrupt onset of symptoms related to both solids and liquids associated with atypical chest pain, the primary concern should be for esophageal spasm.
ONE MORE TEST
4. What study would you order next to better elucidate the cause of this patient’s esophageal disorder?
- High-resolution esophageal manometry
- Esophagogastroduodenoscopy (EGD) with endoscopic ultrasonography
- 24-hour pH and impedance testing
- Wireless motility capsule
Esophageal manometry (Figure 2) is used to evaluate the function and coordination of the muscles of the esophagus, as in disorders of esophageal motility.
High-resolution manometry is the gold standard for evaluation of esophageal motility. It is appropriate in evaluating dysphagia or noncardiac chest pain without evidence of mechanical obstruction, ulceration, or inflammation.4,5
High-resolution manometry differs from conventional manometry in that the catheter has more sensors to measure intraluminal pressure (36 rather than the usual 7 to 12). The data are translated into pressure topography plots (Figure 3).6,7
Updated guidelines on how to interpret the findings of high-resolution manometry are known as the Chicago 3.0 criteria.4 According to this system, esophageal motility disorders are grouped on the basis of lower esophageal sphincter relaxation and then further subdivided based on the character of peristalsis.
EGD with endoscopic ultrasonography would not be appropriate at this time because there is little suspicion of an extraluminal mass that needs to be investigated.
A 24-hour pH and impedance study is helpful in determining the presence of esophageal acid exposure in patients presenting with gastroesophageal reflux disease. This patient does not have symptoms of heartburn or regurgitation; therefore, this investigation would not be of value.
A wireless motility capsule would help in investigating gastric and small-bowel motility and may be useful in the future for this patient, but at this point it would provide little additional utility.
ESOPHAGEAL SPASM
Our patient underwent high-resolution esophageal manometry. The results (Figure 4) revealed a normal resting pressure in the lower esophageal sphincter and complete relaxation in all swallows. The body of the esophagus demonstrated premature contractions in 90% of swallows. Overall, these findings were consistent with the diagnosis of distal esophageal spasm.
