Dysphagia

Progressive dysphagia initially for solids and later for liquids is the hallmark feature of carcinoma of hypopharynx and cervical esophagus.

Hypopharynx lesions usually presents with sore throat, hoarseness, otalgia and foreign body sensation. 

Classic causes of Intermittent dysphagia are diffuse esophageal spasm and schatzki ring.

Also know:

• Dysphagia more for solid than liquid implies mechanical obstruction (Ca esophagus, stricture, webs)
• Dysphagia equal for both solid and liquid from the very onset suggests motor disorder i.e achalasia and diffuse esophageal spasm.

Ref: Harrison 17/e, Page 239; CMDT 2005, Page 546.

Answer is C (Pharyngeal diverticulum)

Progressive

• Achalasia
• Progressive systemic sclerosis
• Peptic stricture
• Carcinoma

Intermittent

• Lower esophageal ring/Spatzki ring
• Diffuse esophageal spasm
• Zenker’s diverticulum

Answer is D (Manometry)

Esophageal manometry is the gold standard test for esophageal motility disorders.

Esophageal Motility Disorders : Manometry is the test of choice Achalasia Cardia

Diffuse Oesophageal Spasm (Discoordinated motility) Nutcracker Oesophagus (Hypercontractile motility)

Hypertensive LES (Hypercontractile motility)

Hypotensive LES(Hypocontractile motility)

Ineffective Oesophageal motility (Hypocontractile motility)

Answer is A (Barium swallow)

Presence of progressive dysphagia for both liquids and solids suggest a probable diagnosis of Achalasia Cardia. Barium swallow should be the first / initial investigation.

‘In evaluating a patient with dysphagia. a barium .swallow should be the first test performed’

Ans:C.)Schatzki ring.

The above esophagram shows a Schatzki ring (red arrow) at the distal esophagus.

Schatzki Ring

• Distal Esophageal rings are usually associated with episodic solid food dysphagia and are called Schatzki rings.
• Patients typically present older than 40 years, consistent with an acquired rather than congenital origin.
• Schatzki ring causes intermittent food impaction, also known as steakhouse syndrome.
• Symptomatic rings are treated by dilatation.

Ans:B.)Esophageal Carcinoma.

Image demonstrate an irregular, somewhat nodular filling defect (white arrows) stretching for a considerable part of the distal esophagus, narrowing the lumen. There is a shelf-like defect approximately where the tumor begins (red arrows).

Esophageal Carcinoma

• Chronic gastric reflux (Barrett’s esophagus)

• Alcohol
• Cigarette
• Mucosal damage from physical agents: long term ingestion of hot liquids, lye (caustic ingestion), radiation induced strictures and chronic achalasia
• Other ingested carcinogens: Nitrates, nitrites, nitrosamines, smoked opiates and fungal toxins in packed vegetables.
• Plummer-Vinson-paterson-kelly syndrome (esophageal web + glossitis + Iron deficiency)
• Tylosis palmaris et plantaris (congenital hyperkeratosis and pitting of palms and soles)
• Human papillomavirus
• Bulimia (repeated microtrauma due to vomiting, may contribute to the malignant transformation of the esophageal tissue)
• Esophageal diverticula