17th July 2023

Oesophageal Dysphagia

Oesophageal dysphagia is characterised by the sensation of food being obstructed in the oesophagus after eating (patients often describe that ‘food sticks’). The dysphagia occurs several seconds after initiating a swallow. We can broadly divide causes of oesophageal dysphagia into 1) mechanical obstruction and 2) motility/neuromuscular disorders. As mentioned above, some causes listed here may also give an oropharyngeal picture.

Table 5: Causes of oesophageal dysphagia

Investigations

• Fluoroscopy (i.e. barium swallow)
• Gastroscopy – good at visualising mechanical obstructions and is important to exclude cancers
• Oesophageal manometry – performed in patients with non-diagnostic gastroscopies and/or clinical suspicion of oesophageal motility disorders
  • Achalasia will show increased pressure at the lower oesophageal sphincter, whereas CREST syndrome will show lower pressure

Patients with ongoing symptoms but with no evidence of structural, endoscopic, histopathological or manometric abnormality may have functional dysphagia.

Achalasia

Achalasia is characterised by the failure of the Lower Oesophageal Sphincter (LES) to relax as a result of the degeneration of ganglion nerve cells in the myenteric plexus. Patients typically describe dysphagia to both solids and liquids as well as retrosternal discomfort following meals. Secondary causes of achalasia include malignancy, Chagas disease and amyloidosis.

Investigations: Barium swallow studies may reveal a typical bird’s beak appearance at the lower oesophagus (see image below). However, oesophageal manometry is the gold standard diagnostic test in which the LES will fail to relax.

Treatment: this is guided by the patient’s preference and surgical risk. More definitive treatments include surgical myotomy or endoscopic pneumatic dilatation. If this is not suitable, alternative treatments include botulinum injections at the LES and/or medications such as calcium channel blockers and nitrates (medical management is often the least effective).

Barium swallow showing bird’s beak appearance that is seen in achalasia

Image Source: Wikimedia Commons (2007). Acha, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Acha.JPG (Accessed on: 9 June 2022).