17th July 2023

Diseases of the Oesophagus

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).

Gastro-Oesophageal Reflux Disease (GORD)

GORD is a common condition, which can be defined as the reflux of gastric acid into the oesophagus, causing mucosal injury (erosive oesophagitis) or symptoms. Mild cases may be diagnosed clinically and managed in primary care without the need for further investigation. However, the gold standard diagnostic test is ambulatory 24-hour pH monitoring ― this will help differentiate GORD from functional dyspepsia. Endoscopy may be required if patients have ALARM symptoms or have refractory disease.

Management

• Lifestyle measures ― weight management, smoking cessation, modify caffeine, alcohol, and spicy foods
• Medication review (common culprit medications – bisphosphonates, NSAIDs, steroids, calcium channel blockers)
• Medical management ― H2 antagonists, proton-pump inhibitors, antacids, surface agents (sucralfate)
• Invasive procedures ― endoscopic v surgical (Nissen’s fundoplication)

Complications

GORD can result in a number of oesophageal and extra-oesophageal complications.

Oesophageal:

• Erosive oesophagitis
• Barrett’s oesophagus ― normal oesophageal squamous epithelium undergoes metaplasia and becomes columnar epithelium in response to acid exposure. This increases the risk of oesophageal adenocarcinoma. Therefore, patients are risk stratified to determine the frequency of endoscopic surveillance. Some patients may require interventions such as radio-frequency ablation (RFA)
• Oesophageal strictures

Extra-oesophageal:

• Dental issues
• Asthma
• Chronic laryngitis

Oesophageal Cancers

There are two main forms of oesophageal malignancy:

• Squamous Cell Carcinoma (SCC) – most commonly located in the upper ⅔ of the oesophagus
• Adenocarcinoma – most commonly located in the lower ⅓ of the oesophagus

Traditionally, SSC has been more prevalent in Western nations, however, in the last century, adenocarcinoma has become the leading cause of oesophageal cancer. Key symptoms include dysphagia and weight loss. Unfortunately, many patients with oesophageal cancer present late with unresectable, locally advanced disease. There are various risk factors (Table 6).

Table 6: Risk factors for squamous cell carcinoma and adenocarcinoma of the oesophagus

Other Oesophageal Disorders

• Mallory-Weiss Tear ― an oesophageal mucosal tear, often caused by severe vomiting or coughing. This can result in an upper GI bleed.
• Boerhaave’s perforation ― a sudden rupture of the oesophagus due to raised intra-oesophageal pressure and reduced intrathoracic pressure (e.g. severe vomiting). Patients may have severe retrosternal chest pain (intrathoracic perforation), abdominal pain with radiation to the shoulders (intra-abdominal perforation) and subcutaneous emphysema.
• Eosinophilic oesophagitis ― a history may mention a young patient with a history of recurrent food bolus obstruction (perhaps with certain trigger foods causing an allergic reaction). Patients will show no improvement to PPI trials. Endoscopy may be normal but oesophageal rings may be present. Diagnostic biopsies show ≥15 eosinophils per high power field. Treatments can be difficult and include eliminating trigger foods, topical steroids and dilatation where oesophageal strictures are present.
• Plummer-Vinson syndrome ― a triad of iron deficiency anaemia, dysphagia (secondary to an oesophageal web) and glossitis/angular cheilitis. Oesophageal webs can result in dysphagia.