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Symptoms of Esophageal Disease


Common symptoms that affect the esophagus include dysphagia, odynophagia, globus sensation, hiccups, chest pain, heartburn, regurgitation, and a number of “supraesophageal” complaints that have been attributed to gastroesophageal reflux. A carefully taken history can clarify many of these symptoms and is followed by selected testing, therapeutic trials, or both. Dysphagia is either proximal or distal and can be to solids only or to liquids and solids. Barium testing, manometry, and endoscopy are appropriate tests in a patient with dysphagia. Odynophagia usually indicates mucosal disease and should lead to endoscopy in most situations. The evaluation of globus sensation and hiccups usually does not yield a specific disorder, and the management is thus challenging. Chest pain can originate from the esophagus and frequently responds to gastric acid suppression. If reflux is not present, the evaluation and treatment of chest pain become challenging. Typical (heartburn and regurgitation) and extraesophageal symptoms potentially caused by GERD may respond to a diagnostic and therapeutic trial of acid suppression. Ambulatory pH testing is the best method to confirm reflux in these patients. Many of these esophageal symptoms may also occur in a patient with no objective evidence of pathology and are then considered and treated as functional disorders.

Symptoms related to the esophagus are among the most common in general medical as well as gastroenterologic practice. For example, dysphagia becomes more common with aging and affects up to 15% of persons age 65 or older. Heartburn, regurgitation, and other symptoms of GERD are also common. A survey of healthy subjects in Olmsted County, Minnesota, found that 20% of persons, regardless of gender or age, experienced heartburn at least weekly. Mild symptoms of GERD rarely indicate severe underlying disease but must be addressed, especially if they have occurred for many years. Frequent or persistent dysphagia or odynophagia suggests an esophageal problem that necessitates investigation and treatment. Other less specific symptoms of possible esophageal origin include globus sensation, chest pain, belching, hiccups, rumination, and extraesophageal complaints like wheezing, coughing, sore throat, and hoarseness, especially if other causes have been excluded. A major challenge in evaluating esophageal symptoms is that the degree of esophageal damage often does not correlate well with the patient’s or physician’s impression of symptom severity. This is a particular problem in older patients, in whom the severity of gastroesophageal reflux-induced injury to the esophageal mucosa is increased despite an overall decrease in the severity of symptoms.

Dysphagia

Dysphagia , from the Greek dys (difficulty, disordered) and phagia (to eat), refers to the sensation that food is hindered in its passage from the mouth to the stomach. Most patients complain that food sticks, hangs up, or stops, or they feel that the food “just won’t go down right.” Occasionally they complain of associated pain. If asked, “Do you have trouble swallowing?” some patients with dysphagia in the lower esophagus will actually say no because they may only think of swallowing as the transfer of food from the mouth to the esophagus. Patients with a dilated esophagus, particularly due to achalasia, may incorrectly interpret dysphagia as regurgitation or even vomiting. Dysphagia always indicates malfunction of some type in the oropharynx or esophagus, although associated psychiatric disorders can amplify this symptom.

Pathophysiology

Inability to swallow is caused by a problem with the strength or coordination of the muscles required to move material from the mouth to the stomach or by a fixed obstruction somewhere between the mouth and stomach. Occasionally patients may have a combination of the two processes. The oropharyngeal swallowing mechanism and the primary and secondary peristaltic contractions of the esophageal body that follow usually transport solid and liquid boluses from the mouth to the stomach within 10 seconds. If these orderly contractions fail to develop or progress, the accumulated bolus of food distends the esophageal lumen and causes the discomfort associated with dysphagia. In some patients, particularly older adults, dysphagia is the result of low-amplitude primary or secondary peristaltic activity that is insufficient to clear the esophagus. High-resolution manometry has identified areas of weak or absent peristalsis of varying lengths (peristaltic gaps) that may explain dysphagia in some patients who have a normal conventional manometry result. Other patients have a primary or secondary motility disorder that grossly disturbs the orderly contractions of the esophageal body. Because these motor abnormalities may not be present with every swallow, dysphagia may wax and wane (see also Chapter 44 ).

Mechanical narrowing of the esophageal lumen may interrupt the orderly passage of a food bolus despite adequate peristaltic contractions. Symptoms vary with the degree of luminal obstruction, associated esophagitis, and type of food ingested. The normal esophagus distends in advance of a bolus’s arrival. Patients with a poorly distensible esophagus (e.g., due to eosinophilic esophagitis or radiation esophagitis) may experience dysphagia even though the esophagus does not appear to be narrowed during EGD or barium swallow (see later). Although minimally obstructing lesions cause dysphagia only with large poorly chewed boluses of foods like meat and dry bread, lesions that obstruct the esophageal lumen completely lead to symptoms with solids and liquids. GERD may produce dysphagia related to an esophageal stricture, but some patients with GERD clearly have dysphagia in the absence of a demonstrable stricture, and perhaps even without esophagitis. Abnormal sensory perception in the esophagus may lead to the feeling of dysphagia even when the bolus has cleared the esophagus. Because some normal test subjects experience the sensation of dysphagia when the distal esophagus is distended by a balloon, as well as by other intraluminal stimuli, an aberration in visceral perception could explain dysphagia in patients who have no definable cause. This mechanism may also apply to amplification of symptoms in patients with spastic motility disorders, in whom the frequency of psychiatric disorders is increased.

Differential Diagnosis and Approach

When faced with a patient who complains of dysphagia, the health care provider should approach the problem in a systematic way. Most patients can localize dysphagia to the upper or lower portion of the esophagus, although occasional patients with a distal esophageal cause of dysphagia will present with symptoms referred only to the suprasternal notch or higher. The approach to dysphagia can be divided into oropharyngeal and esophageal dysphagia, although considerable overlap may occur in certain groups of patients. An attempt should be made to determine whether the patient has difficulty only with solid boluses or with both liquids and solids.

Oropharyngeal Dysphagia

With processes that affect the mouth, hypopharynx, and upper esophagus, the patient is often unable to initiate a swallow and must repeatedly attempt to swallow. Patients frequently describe coughing or choking when they attempt to eat. The inability to propel a food bolus successfully from the hypopharyngeal area through the upper esophageal sphincter (UES) into the esophageal body is called oropharyngeal or transfer dysphagia . The patient is aware that the bolus has not left the oropharynx and locates the site of symptoms specifically to the region of the cervical esophagus. Dysphagia that occurs immediately or within one second of swallowing suggests an oropharyngeal abnormality. At times, a liquid bolus may enter the trachea or nose rather than the esophagus. Some patients describe recurrent bolus impactions that require manual dislodgement In severe cases, saliva cannot be swallowed, and the patient drools. Families are tempted to perform the Heimlich maneuver in such instances, but this is not appropriate unless the bolus is producing airway compromise. They should be informed that if the patient can speak, the airway is functional and forcing an esophageal bolus proximally may cause rather than prevent aspiration. Abnormalities of speech like dysarthria or nasal speech may be associated with oropharyngeal dysphagia. Systemic neurologic and neuromuscular conditions such as Parkinson disease, amyotrophic lateral sclerosis, and polymyositis can present with dysphagia as a predominant and occasionally only symptom. Oral pathology should be considered as well; poor teeth or poorly fitting dentures may disrupt mastication and result in an attempt to swallow an overly large or poorly chewed bolus. Loss of salivation—caused by medications, radiation, or primary salivary dysfunction—may result in a bolus that is difficult to swallow.

Recurrent bouts of pulmonary infection may reflect spillover of food into the trachea because of inadequate laryngeal protection. Hoarseness may result from recurrent laryngeal nerve dysfunction or intrinsic muscular disease, both of which cause ineffective vocal cord movement. Weakness of the soft palate or pharyngeal constrictors causes dysarthria and nasal speech as well as pharyngonasal regurgitation. Swallowing associated with a gurgling noise may be described by patients with Zenker diverticulum. Finally, unexplained weight loss may be the only clue to a swallowing disorder; patients avoid eating because of the difficulties encountered. Potential causes of oropharyngeal dysphagia are shown in Box 13.1 .

BOX 13.1
Causes of Oropharyngeal Dysphagia
UES , upper esophageal sphincter.

Neuromuscular ∗

  • Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease)

  • CNS tumors (benign or malignant)

  • Idiopathic UES dysfunction

  • Manometric dysfunction of the UES or pharynx †

    † Many manometric disorders (hypertensive and hypotensive UES, abnormal coordination, and incomplete UES relaxation) have been described, although their true relationship to dysphagia is often unclear.

  • Multiple sclerosis

  • Muscular dystrophy

  • Myasthenia gravis

  • Parkinson disease

  • Polymyositis or dermatomyositis

  • Postpolio syndrome

  • Stroke

  • Thyroid dysfunction

Structural

  • Carcinoma

  • Infections of pharynx or neck

  • Osteophytes and other spinal disorders

  • Prior surgery or radiation therapy

  • Proximal esophageal web

  • Thyromegaly

  • Zenker diverticulum

∗ Any disease that affects striated muscle or its innervation may result in dysphagia.

After an adequate history is obtained, the initial test is a carefully conducted barium radiographic examination, which is optimally performed with the assistance of a swallowing therapist (modified barium swallow). If the study is normal with liquid barium, the examination is repeated after the patient is fed a solid bolus to bring out the patient’s symptoms and thereby aid in localizing any pathology. If the oropharyngeal portion of the study is normal, the remainder of the esophagus should be examined. The modified barium swallow usually identifies the problem and directs initial therapy.

Esophageal Dysphagia

Most patients with esophageal dysphagia localize their symptoms to the lower sternum or, at times, the epigastric region. A smaller number of patients describe a sensation in the suprasternal notch or higher even though the bolus stops in the lower esophagus. Esophageal dysphagia can frequently be relieved by various maneuvers like repeated swallowing, raising the arms over the head, throwing the shoulders back, and using the Valsalva maneuver. Motility disorders or mechanical obstructing lesions can cause esophageal dysphagia. To clarify the origin of symptoms of esophageal dysphagia, the answers to three questions are crucial:

  • 1.

    What type of food or liquid causes symptoms?

  • 2.

    Is the dysphagia intermittent or progressive?

  • 3.

    Does the patient have heartburn?

On the basis of these answers, distinguishing the several causes of esophageal dysphagia ( Box 13.2 ) as a structural (mechanical) or a neuromuscular (motility) defect and postulating the specific cause are often possible ( Fig. 13.1 ).

BOX 13.2
Common Causes of Esophageal Dysphagia
LES , lower esophageal sphincter.

NEUROMUSCULAR (MOTILITY) Disorders

Primary

  • Achalasia

  • Distal esophageal spasm

  • Hypercontractile (jackhammer) esophagus

  • Hypertensive LES

  • Nutcracker (high-pressure) esophagus

  • Other peristaltic abnormalities ∗

    ∗ Peristaltic abnormalities include absent peristalsis and weak peristalsis, as well as hypertensive peristalsis (nutcracker esophagus).

Secondary

  • Chagas disease

  • Reflux-related dysmotility

  • Scleroderma and other rheumatologic disorders

Structural (Mechanical) Disorders

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