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Esophageal Disorders
Jason Ryan, MD, MPH
Esophageal Disorders
Symptoms
• Odynophagia: painful swallowing
• Dysphagia: difficulty swallowing
• Liquids, solids, or both
• Dysphagia solids and liquids → motility disorder
• Dysphagia solids only → structural disorder
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Olek Remesz/Wikipedia
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Acute-Onset Dysphagia
Impacted Meat in Esophagus
• Sudden inability to swallow
• Usually caused by food impaction
• Food obstructs esophagus
• Most commonly beef, chicken, and turkey
• Management
• IV Glucagon: relaxes lower esophageal sphincter
• Upper endoscopy to remove food

Public Domain
 Non-Acute Dysphagia

Oropharyngeal AfraTafreeh.com Esophageal

dysphagia dysphagia
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Oropharyngeal Dysphagia Barium Esophagram

(Barium Swallow)
• Difficulty initiating swallowing
• Associated with choking or coughing
• Aspiration of food may occur
• Globus sensation (lump in throat)
• Many neuromuscular or structural causes
• Workup: usually barium esophagram

Wikipedia/Public Domain
Esophageal Dysphagia
• Food stuck seconds after swallowing
• Sensation of food stuck in upper esophagus
• Many causes:
• Motility disorders, malignancy, esophagitis, strictures
• Workup usually begins with endoscopy
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OpenStax College
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Esophageal Motility Disorders

Esophageal Manometry
• Achalasia
• Hypertensive peristalsis
• Diffuse esophageal spasm
• All present similarly: dysphagia and heartburn
• Distinguished by esophageal manometry
• Patient swallows
• Pressure changes in esophagus measured
Achalasia
• Inability to relax lower esophageal sphincter
• Loss of lower esophageal peristalsis
• Loss of ganglion cells in the myenteric plexus
• Causes Trypanosoma cruzi
• Often idiopathic AfraTafreeh.com
• Chronic Chagas disease (Protozoa: Trypanosoma cruzi)

CDC/Public Domain
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Achalasia
Symptoms
• Dysphagia to solids and liquids
• Regurgitation of food
• Retrosternal burning similar to GERD
• Irritation of esophagus by food
• Bad breath
• Accumulation of food in esophagus

Pixabay.com
Achalasia Normal Achalasia
Diagnostic Testing
• Endoscopy:
• Retained food in esophagus
• Cannot pass scope beyond LES
• Esophageal manometry
• Required to establish diagnosis
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• Aperistalsis distal esophagus
• Incomplete LES relaxation
• Elevated resting LES pressure
• Barium swallow
• Dilation of esophagus
• “Bird’s beak”

Farnoosh Farrokhi, Michael F. Vaezi.

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Achalasia
Treatment
• Pneumatic dilation
• Surgical or endoscopic myotomy
• Poor surgical candidates:
• Botulinum toxin injection of LES
• Sublingual nitrates before meals

Vu Hong/Slideplayer
Hypertensive Peristalsis
Nutcracker Esophagus
• Excessive amplitude or duration of contractions Nutcracker Manometry
• Dysphagia for solids and liquids
• Retrosternal burning similar to GERD
• Endoscopy: normal
• Diagnosis: esophageal manometry AfraTafreeh.com
• Normal sequence of esophageal contractions
• High pressures

Public Domain
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Diffuse Esophageal Spasm

Barium esophagram
“Corkscrew” appearance of esophagus

Nevit Dilmen/Wikipedia
Diffuse Esophageal Spasm
Normal DES
• Impaired inhibitory innervation to esophagus
• Excessive simultaneous contractions
• Dysphagia for solids and liquids
• Retrosternal burning similar to GERD
• Chest pain that mimics angina AfraTafreeh.com
• Endoscopy: normal
• Diagnosis: esophageal manometry
• Diffuse high-pressure contractions
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Esophageal Motility Disorders

Hypertensive Peristalsis and Diffuse Esophageal Spasm
• Treated with smooth muscle relaxants
• Proton pump inhibitor for GERD
• 1st line drug treatment: diltiazem
• Alternatives:
• Isosorbide dinitrate
• Sildenafil
• Botulinum toxin injection Diltiazem

Needpix.com/Public Domain
Zenker’s Diverticulum
• Herniation at Killian’s triangle (Killian’s dehiscence)
• Junction of esophagus and pharynx
• Part of the hypopharynx
• Just proximal to upper esophageal sphincter
• Mucosa/submucosa herniate through muscular wall
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• Usually result of chronic swallowing problems
• Cricopharyngeal muscle must relax to allow food to pass
• Failure to relax → difficulty swallowing
• Chronic high pressure in pharynx to force food down
• This leads to diverticulum

Berniece Wilcox/Slideplayer
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Zenker’s Diverticulum
• Progressive oropharyngeal dysphagia
• Usually to solids only
• Regurgitation of undigested food
• Halitosis (food trapped in diverticulum)
• Diagnosis: barium esophagram or endoscopy
• Endoscopy usually done first to exclude malignancy
• ZD can be missed by endoscopy → barium swallow
• Treatment: surgical or endoscopy resection

Dr. Martin Steinhoff

Esophageal Webs and Rings
• Extension/protrusion of mucosa into lumen
• Webs: eccentric membrane often proximal
• Rings: concentric membrane often distal
• Often asymptomatic
• Can obstructs movement of food AfraTafreeh.com Web Ring
• Diagnosis: endoscopy or barium swallow
• Treatment: endoscopic dilation

Public Domain
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Schatzki Ring Schatzki Ring

Barium Esophagram

• Most common type of esophageal ring

• Ring at squamocolumnar junction
• Squamous mucosa proximally, columnar distally
• Common cause of dysphagia to solids

Public Domian
Plummer-Vinson Syndrome Glossitis

• Rare, poorly-understood condition

• Triad:
• Iron deficiency anemia
• Dysphagia
• Esophageal web
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• Beefy red tongue (glossitis)
• Damage to tongue mucosal layer from low iron
• Bright red from exposure of blood vessels
• Common in middle-age, white women
• Increased risk: esophageal squamous cell carcinoma

Martin Kronawitter
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Esophageal Strictures
Esophageal Stricture

• Usually caused by GERD (peptic strictures)

• Diagnosis: endoscopy
• Treatment: endoscopic dilation

Public Domain
Dysphagia Workup
• In actual practice, most cases dysphagia → endoscopy first

Subtype Best Test

Oropharyngeal Dysphagia --
AfraTafreeh.com Barium Esophagram
Esophageal Dysphagia Solids only Endoscopy
Progressive solids → liquids Endoscopy
Manometry or
Solids and liquids at onset
Barium Esophagram
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Infectious Esophagitis
• Candida
• White membranes HSV Esophagitis Esophageal Candidiasis
• Pseudohyphae on biopsy
• HSV-1
• Usually causes oral herpes
• Can involve esophagus
• “Punched out” ulcers
• CMV
• AIDS (CD4<50)
• Linear ulcers

Samir/Wikipedia
Infectious Esophagitis
HIV patients
• Presents as odynophagia or dysphagia
• Mild symptoms and/or thrush → empiric treatment with fluconazole
• Severe symptoms with no thrush → endoscopy

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Finding Diagnosis Treatment

White plaques Candida Fluconazole
Linear ulcers CMV Ganciclovir
Punched out ulcers
HSV Acyclovir
or Vesicles
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Eosinophilic Esophagitis
• Allergic reaction
• Esophageal dysfunction include dysphagia
• Biopsy: eosinophil-predominant inflammation
• Diagnosis of exclusion
• Must rule out other causes of esophagitis (i.e. GERD)

Nephron/Wikipedia
Eosinophilic Esophagitis
• Classic scenario:
• Dysphagia
• Poor response to GERD treatment
• Eosinophils on biopsy
• First-line treatment: dietary modification
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• Food allergy testing
• Elimination diet
• Other treatments
• Fluticasone inhaler – sprayed/swallowed

Nephron/Wikipedia
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Food Impaction
Prevention of recurrence
Impacted Meat in Esophagus
• Recurrent impactions: 10 to 20% of cases
• Common additional tests/treatment:
• Biopsy for eosinophilic esophagitis
• Dilation of strictures or a Schatzki ring
• Evaluation for esophageal motility disorder

Public Domain
Mallory-Weiss Tear
• Damage to esophageal mucosa at GE junction
• Causes painful hematemesis
• Epigastric pain or pain in the back
• Often caused by severe, chronic vomiting
• Alcohol use AfraTafreeh.com
• Bulimia
• Iatrogenic: NG tube
• Diagnosis: endoscopy
• Treatment: PPI +/- endoscopic therapy

Public Domain
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BoerHaave Syndrome
• Effort-related transmural rupture of esophagus
• Not caused by trauma
• Caused by severe vomiting or retching
• Air exits esophagus
• Air in mediastinum on chest x-ray (pneumomediastinum)
• Air under skin in neck (“subcutaneous emphysema”)
• Gastric contents may enter mediastinum
• Chest pain
• Dysphagia

Jto410/Wikipedia
BoerHaave Syndrome
• Suggested by clinical features and x-ray
• Diagnosis established by either: contrast esophagram
• Establishes exact location of perforation
• Water-soluble contrast (Gastrografin)
• Used instead of barium for esophagram
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• Avoids inflammatory response in mediastinum
• Alternative: CT chest
• Shows edema, air but not precise location
• Treatment:
• NPO, antibiotics, PPI
• Surgical repair in some cases

https://www.med-ed.virginia.edu/