Esophageal Diseases

Gastroenterology
Disorders of the esophagus
With Kelley Chuang, M.D.
Led Joestar, pifeli2160@zevars.com

Powered by TCPDF (www.tcpdf.org)
© www.lecturio.com | This document is protected by copyright.
Overview of Esophageal Disorders
• General principles • Diffuse esophageal spasm
• Approach to dysphagia and odynophagia • Gastroesophageal reflux disease (GERD)
• Esophagitis • Hiatal hernia
• Achalasia • Barrett esophagus
• Esophageal webs and diverticula • Esophageal cancer

Learning Objectives
In this lecture, you will learn how to
• differentiate between motility and

mechanical disorders of the esophagus.
• describe basic diagnostic and

management steps in disorders of the
esophagus.
• identify alarm features of

gastroesophageal reflux disease (GERD).
• identify common complications of

GERD.

Important Definitions
Dysphagia: difficulty with swallowing

Odynophagia: pain with swallowing

Additional Important Definitions
Nasopharynx Oropharyngeal dysphagia:

Oropharynx difficulty passing food from
Laryngopharynx the oropharynx to the upper
esophagus
Esophagus
Esophageal dysphagia:
difficulty passing food from
Lower the upper esophagus into
esophageal the stomach
sphincter
© by Lecturio
Important Historical Risk Factors
Dysphagia to solids, liquids, or both?
Associated symptoms: weight loss,

hoarseness, dysarthria, regurgitation?
What medications?
History of smoking or alcohol use?
History of GERD or acid reflux?

Types of Esophageal Dysphagia
The type of food with which a patient experiences dysphagia

can help determine the underlying etiology.
Dysphagia to liquids or
Dysphagia to solids = both liquids and solids =
mechanical obstruction motility disorder or
complete obstruction

What Are the Best Diagnostic Tests?
These tests can be done to assist in

diagnosis of the cause of dysphagia:
• Barium swallow
• Upper endoscopy
• Esophageal manometry
• pH monitoring
Barium swallow. Dilated esophagus with
© 2007 Farrokhi and Vaezi; licensee BioMed Central Ltd., Figure 2, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2040141/figure/F2/, CC BY
2.0, no changes

• Barium swallow
• Upper endoscopy
• pH monitoring
Endoscopy showing esophageal stenosis.

© Savino et al. 2015, CC0 1.0

• Barium swallow
• Upper endoscopy
• pH monitoring
(A) Normal lower esophageal sphincter pressure and
esophageal peristalsis (B) Hypotonic LES and normal peristalsis
and (C) Ineffective esophageal motility and hypotonic LES.
© 2016 Sánchez-Montalvá et al, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4744054/figure/pntd.0004416.g001/, CC BY 4.0, no changes
pH monitoring catheter
pH sensor

• Barium swallow
• Upper endoscopy Reflux
• pH monitoring Monitoring device

records pH in
esophagus
© by Lecturio
44-year-old Man with HIV Complaining of Painful Swallowing Test case
A 44-year-old man with HIV presents to urgent care Odynophagia in a patient

complaining of painful swallowing with both liquids and solids. with HIV off antiretroviral
He otherwise feels well. He takes no medications. He stopped therapy
taking antiretroviral medications 2 years ago after he moved to Normal exam
a new city, and has not yet established with a new primary care White, raised, thick plaques
doctor. throughout the esophagus
On exam, vitals are normal. Oropharynx appears normal.
Abdominal exam is unremarkable. Upper endoscopy findings
are shown here.
What is the best next step in management?
© 2016 Wolters Kluwer Health, Inc. All rights reserved., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4839949/figure/F1/, CC BY 4.0, no
changes
44-year-old Man with HIV Complaining of Painful Swallowing Test case

taking antiretroviral medications 2 years ago after he moved to Normal exam
a new city, and has not yet established with a new primary care White, raised, thick plaques
doctor. throughout the esophagus
are shown here.
Most likely diagnosis: esophageal thrush, or Candida albicans
changes
Esophagitis 3 Main Types
Infectious esophagitis Pill-induced esophagitis Eosinophilic esophagitis
F.l.t.r.: © 2016 Wolters Kluwer Health, Inc. All rights reserved., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4839949/figure/F1/, CC BY 4.0,
cropped; © 2016 Petros Zezos et al., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4904706/figure/fig1/. CC BY 4.0, cropped; © 2015 Arens
et al., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4702052/figure/F14/, CC BY 4.0, cropped
Infectious Esophagitis
Causative Affected patients Appearance on upper Treatment

organism endoscopy
Candida albicans Both White, raised plaques on Fluconazole
(fungal) immunocompromised endoscopy
and immunocompetent
Cytomegalovirus Immunocompromised Small, deep ulcerations Ganciclovir or

(viral) valganciclovir
Herpes simplex Both, but mostly Large, superficial Acyclovir

virus (viral) immunocompromised ulcerations

Pill-induced Esophagitis
Upper endoscopy showing stellate erosions

consistent with pill-induced esophagitis.
© 2016 Petros Zezos et al., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4904706/figure/fig1/. CC BY 4.0, cropped
Pill-induced Esophagitis
Prevention is key: Advise patients to drink

plenty of water with medications, avoid lying
down for 30 mins after ingesting pills.

Eosinophilic Esophagitis (EoE)
• Esophageal squamous mucosal inflammation from eosinophilic infiltration
• Keywords: young man with atopy presenting with dysphagia and frequent food impactions
• Associations: food allergies, asthma, eczema, GERD

Eosinophilic Esophagitis (EoE)
• Diagnosis with upper

endoscopy:
A. Longitudinal furrows
B. Fragile mucosa
C. Rings trachealized
esophagus)
D. Small white plaques that

may mimic candidiasis
• Treatment: 8-week trial of PPI,

or topical glucocorticoids
2010, Lucendo et al., Figure 1, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139871/figure/F1/, CC BY 2.0, no changes
44-year-old Man with HIV Complaining of Painful Swallowing Answer
Test case

taking antiretroviral medications two years ago after he moved Normal exam
to a new city, and has not yet established with a new primary White, raised, thick plaques
care doctor. throughout the esophagus
are shown below.
Answer: Treat with oral fluconazole
changes
55-year-old Man with Months of Difficulty Swallowing Test case
A 55-year-old man presents to clinic complaining of several Chronic dysphagia

months of difficulty swallowing. He notes mild chest discomfort
immediately after swallowing. He sometimes regurgitates Regurgitation and halitosis
undigested food and complains of bad breath. He has lost 3 kg are features of esophageal
(6.6 lb) unintentionally. He does not smoke or drink alcohol, diverticula
and he denies symptoms of acid reflux.
On exam, vitals are normal. Abdominal exam is unremarkable. Normal exam

Oropharynx exam is clear and benign.
What is the best diagnostic step to confirm the diagnosis?

Esophageal Diverticula
• Due to muscular weakness in the

esophageal wall, usually from
underlying motility disorder
• Most common type: Zenker

diverticulum (outpouching
through cricopharyngeal muscle Cricopharyngeal
in upper 3rd of esophagus) muscle
• Presents with dysphagia, halitosis,

regurgitation of undigested food, diverticulum
chest pain, chronic cough
© by Lecturio
Esophageal Diverticula
• Diagnosis: barium swallow study
• Treat with myotomy to relieve high pressure and correct underlying motility disorder

55-year-old Man with Months of Difficulty Swallowing Answer
Test case
A 55-year-old man presents to clinic complaining of several Chronic dysphagia

months of difficulty swallowing. He notes mild chest discomfort
immediately after swallowing. He sometimes regurgitates Regurgitation and halitosis
undigested food and complains of bad breath. He has lost 3 kg  features of esophageal
(6.6 lb) unintentionally. He does not smoke or drink alcohol, diverticula
and he denies symptoms of acid reflux.
On exam, vitals are normal. Abdominal exam is unremarkable. Normal exam

Oropharynx exam is clear and benign.
What is the best diagnostic step to confirm the diagnosis?
Answer: barium swallow

A 62-year-old Woman with Dysphagia and Weight Loss Test case
A 62-year-old woman presents to Chronic intermittent

clinic complaining of intermittent dysphagia to both solids
difficulty with swallowing for the past 5 and liquids motility
years. She has trouble with both solids disorder
and liquids. In the last two months she
has noted that she frequently Regurgitation and weight
regurgitates undigested food and is loss
losing weight.
Vitals are normal. Oropharynx and
abdominal exams are unremarkable. Barium swallow shows
Lab studies are normal. typical beak
appearance
A barium swallow study is shown to
the right.
What is the most likely diagnosis?

2.0, no changes
Achalasia
Normal esophagus Esophagus dilates
Lower esophageal LES relax

sphincter (LES)
© by Lecturio
Achalasia
• Diagnosis:
• Barium swallow study
• Upper endoscopy to rule out

mechanical obstruction or cancer
• Manometry to confirm diagnosis
• Treat: botulinum toxin injection,

endoscopic dilation, or surgical myotomy
on barium swallow
with retained contrast in the esophagus.
2.0, no changes
A 62-year-old Woman with Dysphagia and Weight Loss Test case

difficulty with swallowing for the past 5 and liquids  motility
regurgitates undigested food and is loss  esophageal
losing weight. diverticula or achalasia
abdominal exams are unremarkable.
Lab studies are normal. Barium swallow shows
A barium swallow study is shown to typical
the right. appearance

2.0, no changes
A 62-year-old Woman with Dysphagia and Weight Loss Answer
Test case

difficulty with swallowing for the past 5 and liquids  motility
regurgitates undigested food and is loss  esophageal
losing weight. diverticula or achalasia
abdominal exams are unremarkable.
Lab studies are normal. Barium swallow shows
A barium swallow study is shown to typical
the right. appearance
Answer: achalasia
2.0, no changes
48-year-old Woman with Severe Chest Pain Test case
A 48-year-old woman presents to the emergency department Sudden onset pain that
complaining of sudden intermittent episodes of severe chest mimics cardiac angina
pain. She also notes difficulty with swallowing both liquids and
solids when these episodes occur. She has no known medical Difficulty with both solids
conditions and no family history of cardiac disease. and liquids
Vitals are normal. On exam, oropharynx and cardiac exam are

normal.
What is the best test to confirm the diagnosis?

Diffuse Esophageal Spasm
• Hypertonic motility disorder
• Presents with chest pain that mimics cardiac

angina and dysphagia to both liquids and
solids during episodes
• Barium swallow study may show

esophagus
• Diagnosis made by esophageal manometry,

which will show high-amplitude contractions
throughout the esophagus
Normal manometry
• Treatment: symptom relief with calcium
channel blockers, botulinum toxin injections
Fernando Augusto Herbella, Priscila Rodrigues Armijo and Marco Giuseppe Patti, Figure 1,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5234762/, CC BY 4.0, no changes
Diffuse Esophageal Spasm
• Hypertonic motility disorder
• Presents with chest pain that mimics cardiac

angina and dysphagia to both liquids and
solids during episodes
• Barium swallow study may show

esophagus
• Diagnosis made by esophageal manometry,

which will show high-amplitude contractions
throughout the esophagus
• Treatment: symptom relief with calcium Manometry showing hypercontractile esophagus

channel blockers, botulinum toxin injections
Fernando Augusto Herbella, Priscila Rodrigues Armijo and Marco Giuseppe Patti, Figure 3,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5234762/ CC BY 4.0, no changes
48-year-old Woman with Severe Chest Pain Test case
conditions and no family history of cardiac disease. and liquids  motility
disorder
normal.
Most likely diagnosis:
What is the best test to confirm the diagnosis? diffuse esophageal spasm

48-year-old Woman with Severe Chest Pain Answer
Test case
conditions and no family history of cardiac disease. and liquids  motility
disorder
normal.
Most likely diagnosis:
What is the best test to confirm the diagnosis? diffuse esophageal spasm
Answer: best diagnostic test is esophageal manometry

(barium swallow study may be falsely normal if no episodes
occur during study)

A 52-year-old Man with Burning Sensation in His Chest Test case
A 52-year-old man is seen in clinic complaining of a burning Heartburn exacerbated by

sensation in his chest for the past 6 weeks. His symptoms are lying flat and large meals is
worse at night and after he eats a large meal. He has tried typical of GERD
over-the-counter antacids with some relief but still has
symptoms. He has not had any difficulty swallowing or OTC antacids (H2 blockers)
unintentional weight loss. offer some relief
Vitals and physical exam are normal. No alarm symptoms of

weight loss or dysphagia
What is the best next step in treatment?

Gastroesophageal Reflux Disease (GERD)
Esophagus Lower esophageal LES
• Acid and food from stomach sphincter (LES) open
reflux into esophagus from
incompetent lower esophageal
sphincter
• Symptoms: heartburn,
regurgitation, and chest pain
• Diagnosis: can be made by

clinical history and response to
empiric trial of therapy
• In unclear cases: ambulatory pH

monitoring of esophagus to Healthy stomach Gastric
confirm diagnosis reflux
© by Lecturio
Gastroesophageal Reflux Disease (GERD) Management
Initially: Pharmacologic:
diet and lifestyle changes limited trial of H2 blocker or PPI

GERD Alarm Symptoms
What are alarm symptoms related to GERD?

GERD Alarm Symptoms
Always screen a patient with GERD for alarm symptoms of

unintentional weight loss, dysphagia, hematemesis, or
melena. If present, refer for upper endoscopy!

A 52-year-old Man with Burning Sensation in His Chest Answer
Test case
A 52-year-old man is seen in clinic complaining of a burning Heartburn exacerbated by

sensation in his chest for the past 6 weeks. His symptoms are lying flat and large meals
worse at night and after he eats a large meal. He has tried  typical of GERD
over-the-counter antacids with some relief but still has
symptoms. He has not had any difficulty swallowing or OTC antacids (H2 blockers)
unintentional weight loss. offer some relief
Vitals and physical exam are normal. No alarm symptoms of

weight loss or dysphagia
What is the best next step in treatment?
Most likely diagnosis: GERD
Answer: Recommend diet and lifestyle modification
and trial of PPI therapy

44-year-old Woman Presents for Follow-up of GERD Test case
A 44-year-old woman presents for GERD treated with

follow-up of GERD. She was started on adequate trial of oral PPI
pantoprazole 8 weeks ago when she (8 weeks of therapy)
first presented with heartburn. She has
had improvement in her heartburn Some symptomatic relief,
symptoms during the day but continues but persistent symptoms
to have heartburn causing awakenings
at night. She takes her pantoprazole 30
minutes before breakfast as directed. Chest x-ray shows a mass
Vitals are normal, and exam is with air-fluid level above
unremarkable. Her chest x-ray is shown level of diaphragm
here.
What is the best next step in

management?
© 2015 Cem Sahin et al., Figure 1, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4502274/figure/fig1/, CC BY 3.0, cropped
Hiatal Hernia
• Type 1: sliding hernia (most Esophagus

common)
• Type 2: paraesophageal hernia Diaphragm

(higher risk)
• Many are asymptomatic, but may

present with heartburn, chest
pain, and dysphagia
• Complications: GERD, reflux

esophagitis, Barrett esophagitis
/malignancy, and aspiration Stomach
• Diagnose by barium swallow

study, X-ray, or upper endoscopy Type 1 Type 2
© by Lecturio
Hiatal Hernia Management
Fundus wrapped around Wrap secured

back side of esophagus with sutures
• Type 1: antacids and lifestyle

modifications for GERD
symptoms; If large or develop
complications, surgery (Nissen
fundoplication)
• Type 2: surgery (due to risk of

enlarging)
Nissen fundoplication
© by Lecturio
Hiatal Hernia Management
Fundus wrapped around Wrap secured

back side of esophagus with sutures
• Type 1: antacids and lifestyle

modifications for GERD
symptoms; If large or develop
complications, surgery (Nissen
fundoplication)
• Type 2: surgery (due to risk of

enlarging)
Nissen fundoplication
© by Lecturio
44-year-old Woman Presents for Follow-up of GERD Answer
Test case
A 44-year-old woman presents for GERD treated with

follow-up of GERD; She was started on adequate trial of oral PPI
pantoprazole 8 weeks ago when she (8 weeks of therapy)
first presented with heartburn. She has
had improvement in her heartburn Some symptomatic relief,
symptoms during the day but continues but persistent symptoms
to have heartburn causing awakenings
at night. She takes her pantoprazole 30
minutes before breakfast as directed. Chest x-ray shows a mass
Vitals are normal, and exam is with air-fluid level above
unremarkable. Her chest x-ray is shown level of diaphragm
here.  represents a large hiatal
hernia
Answer: surgery should be offered
© 2015 Cem Sahin et al., Figure 1, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4502274/figure/fig1/, CC BY 3.0, cropped

A 73-year-old Man with Worsening GERD Symptoms Test case
A 73-year-old man is seen in clinic for follow-up of his GERD. Longstanding GERD
He has had heartburn for the last 15 years, which was
previously well controlled on pantoprazole. In the last few Worsening symptoms
weeks, he has noticed worsening symptoms and a sour taste in despite appropriate therapy
his mouth despite taking his pantoprazole as directed. He has
no dysphagia, weight loss, or vomiting.
No alarm symptoms
Vitals are normal. Exam is unremarkable. Upper endoscopy
shows a small hiatal hernia and dark, pink-colored mucosa in Suspicious endoscopy
the distal esophagus. Biopsies are taken that show columnar findings
epithelium with high-grade dysplasia.

Barrett Esophagus
• Normal squamous epithelium is

replaced by metaplastic columnar
epithelium in distal esophagus
• Risk factors: old age, male

gender, white ethnicity, GERD,
hiatal hernia, high BMI, smoking
• Pre-malignant condition that has

a 0.12 0.5% per year risk of
progressing to esophageal
adenocarcinoma Barrett esophagus Normal esophagus
Esophagus. 2017; 14(1): 1 36., © The Author(s) 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5222932/figure/Fig19/, CC BY 4.0, no

changes
Barrett Esophagus
• Diagnosis: upper endoscopy and histology
• Management: twice-daily PPI, endoscopic ablation for high-grade dysplasia

A 73-year-old Man with Worsening GERD Symptoms Answer
Test case
A 73-year-old man is seen in clinic for follow-up of his GERD. Longstanding GERD
He has had heartburn for the last 15 years, which was
previously well controlled on pantoprazole. In the last few Worsening symptoms
weeks, he has noticed worsening symptoms and a sour taste in despite appropriate therapy
his mouth despite taking his pantoprazole as directed. He has
no dysphagia, weight loss, or vomiting.
No alarm symptoms
Vitals are normal. Exam is unremarkable. Upper endoscopy
shows a small hiatal hernia and dark, pink-colored mucosa in Suspicious endoscopy
the distal esophagus. Biopsies are taken that show columnar findings  Barrett
epithelium with high-grade dysplasia. esophagus
Answer: High-grade dysplasia warrants endoscopic ablation to

prevent progression to adenocarcinoma.

76-year-old Woman with Difficulty Swallowing Solid Foods Test case
A 76-year-old woman is seen in clinic for difficulty swallowing Dysphagia to solids

solid foods for the past 2 months. She has a history of GERD for concerning for mechanical
which she has taken omeprazole for the past 12 years. She has obstruction
no other relevant past medical history. She is a current smoker
and has a 25-pack-year smoking history. Long-standing history of
GERD in a tobacco user
Vitals are normal. Physical exam is unremarkable. Laboratory
studies are normal.

Esophageal Cancer
Esophagus Squamous cell

carcinoma
• 6th leading cause of worldwide
cancer-related mortality
• Two types: squamous cell

carcinoma (SCC) and
adenocarcinoma
• Poor prognosis: 5-year survival

rate of 15 25% depending on
stage at diagnosis
Stomach Adenocarcinoma
© by Lecturio
Esophageal Cancer
Symptoms Diagnosis Management
• Dysphagia to solids, • Upper endoscopy with • Surgery for resectable

weight loss, anorexia, biopsy disease, often with
anemia neoadjuvant
• Staging often done chemoradiation
with CT scan and PET
imaging

Risk Factors for Esophageal Cancer
Squamous cell carcinoma Adenocarcinoma
Tobacco use Tobacco use
Alcohol use Barrett esophagus
Caustic injury GERD
Achalasia Obesity
Poor oral hygiene Male gender
African-American Caucasian

76-year-old Woman with Difficulty Swallowing Solid Foods Answer
Test case
A 76-year-old woman is seen in clinic for difficulty swallowing Dysphagia to solids

solid foods for the past 2 months. She has a history of GERD for concerning for mechanical
which she has taken omeprazole for the past 12 years. She has obstruction
no other relevant past medical history. She is a current smoker
and has a 25-pack-year smoking history. Long-standing history of
GERD in a tobacco user
Vitals are normal. Physical exam is unremarkable. Laboratory
studies are normal.
What is the next best step in diagnosis?
Answer: Recognize high risk for esophageal adenocarcinoma

 next step is upper endoscopy

Learning Outcomes
In the lecture, you have learned how to
 differentiate between motility and

mechanical disorders of the esophagus.
 describe basic diagnostic and management

steps in disorders of the esophagus.
 identify alarm features of gastroesophageal

reflux disease (GERD).
 identify common complications of GERD.

This document is a property of: Led Joestar
Note: This document is copyright protected. It may not be copied, reproduced, used, or
distributed in any way without the written authorization of Lecturio GmbH.


Esophageal Diseases

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Esophageal Diseases

Uploaded by

Copyright:

Available Formats

Gastroenterology

Disorders of the esophagus

With Kelley Chuang, M.D.

Led Joestar, pifeli2160@zevars.com

• General principles • Diffuse esophageal spasm

• Approach to dysphagia and odynophagia • Gastroesophageal reflux disease (GERD)

• Esophagitis • Hiatal hernia

• Achalasia • Barrett esophagus

• Esophageal webs and diverticula • Esophageal cancer

Led Joestar, pifeli2160@zevars.com

In this lecture, you will learn how to

• differentiate between motility and

• describe basic diagnostic and

• identify alarm features of

• identify common complications of

Led Joestar, pifeli2160@zevars.com

Dysphagia: difficulty with swallowing

Led Joestar, pifeli2160@zevars.com

Nasopharynx Oropharyngeal dysphagia:

Dysphagia to solids, liquids, or both?

Associated symptoms: weight loss,

History of smoking or alcohol use?

History of GERD or acid reflux?

Led Joestar, pifeli2160@zevars.com

The type of food with which a patient experiences dysphagia

Led Joestar, pifeli2160@zevars.com

These tests can be done to assist in

Barium swallow. Dilated esophagus with

These tests can be done to assist in

Endoscopy showing esophageal stenosis.

These tests can be done to assist in

These tests can be done to assist in

• Upper endoscopy Reflux

• pH monitoring Monitoring device

A 44-year-old man with HIV presents to urgent care Odynophagia in a patient

A 44-year-old man with HIV presents to urgent care Odynophagia in a patient

Most likely diagnosis: esophageal thrush, or Candida albicans

Infectious esophagitis Pill-induced esophagitis Eosinophilic esophagitis

Causative Affected patients Appearance on upper Treatment

Cytomegalovirus Immunocompromised Small, deep ulcerations Ganciclovir or

Herpes simplex Both, but mostly Large, superficial Acyclovir

Led Joestar, pifeli2160@zevars.com

Upper endoscopy showing stellate erosions

Prevention is key: Advise patients to drink

Led Joestar, pifeli2160@zevars.com

• Esophageal squamous mucosal inflammation from eosinophilic infiltration

• Associations: food allergies, asthma, eczema, GERD

Led Joestar, pifeli2160@zevars.com

• Diagnosis with upper

D. Small white plaques that

• Treatment: 8-week trial of PPI,

A 44-year-old man with HIV presents to urgent care Odynophagia in a patient

Answer: Treat with oral fluconazole

A 55-year-old man presents to clinic complaining of several Chronic dysphagia

On exam, vitals are normal. Abdominal exam is unremarkable. Normal exam

What is the best diagnostic step to confirm the diagnosis?

Led Joestar, pifeli2160@zevars.com

• Due to muscular weakness in the

• Most common type: Zenker

• Presents with dysphagia, halitosis,

• Diagnosis: barium swallow study

Led Joestar, pifeli2160@zevars.com

A 55-year-old man presents to clinic complaining of several Chronic dysphagia