Patient with intractable nausea and vomiting
A chest x-ray—followed by further questioning about the patient’s medical history—revealed the cause of this woman’s symptoms.
Narrowing the causes of dysphagia
The differential diagnosis is broad because there are 2 types of dysphagia: mechanical and neuromuscular.
Mechanical dysphagia is caused by a food bolus or foreign body, by intrinsic narrowing of the esophagus (from inflammation, esophageal webs, benign and malignant strictures, and tumors) or by extrinsic compression (from bone or thyroid abscesses or vascular tightening).
Neuromuscular dysphagia is either a swallowing reflex problem, a disorder of the pharyngeal and striated esophagus muscles, or an esophageal smooth muscle disorder.3 Close attention to the patient’s history and physical exam is key to zeroing in on the proper diagnosis.
On the other hand, food impaction in the esophagus almost always indicates certain etiologies. Benign esophageal stenosis caused by Schatzki rings (B rings) or by peptic strictures is the most common cause of food impaction, followed by esophageal webs, extrinsic compression, surgical anastomosis, esophagitis (eg, eosinophilic esophagitis), and motor disorders, such as achalasia.
First-line therapy is surgery; pharmacologic Tx is least effective
Treatment should be individualized by age, gender, and patient preference; however, there is no definitive treatment for this condition. First-line therapy includes graded pneumatic dilation or laparoscopic myotomy with a partial fundoplication.4 Botulinum toxin injection in the lower esophageal sphincter is recommended for patients who are not good candidates for surgery or dilation.5
