Symptoms of

esophageal
disease

Introduction
Symptoms related to the esophagus are among the most

Common.
Dysphagia becomes more common with aging.
Heartburn,

regurgitation,
and
other
symptoms
gastroesophageal reflux disease (GERD) also are common.

of

Frequent or persistent dysphagia or odynophagia suggests an

esophageal
treatment.

problem

that

necessitates

investigation

and

Other less specific symptoms of possible esophageal origin

include globus sensation, chest pain, belching, hiccups,

rumination, and extraesophageal complaints, such as wheezing,
coughing, sore throat, and hoarseness, especially if other causes
have been excluded.

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.

May associated with pain.

Dysphagia always indicates malfunction of some type

in the oropharynx or esophagus, although associated

psychiatric disorders can amplify this symptom.

PATHOPHYSIOLOGY
The 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 the stomach.

Oropharyngeal Dysphagia
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.
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.

In severe cases, saliva cannot be swallowed, and the

patient drools.

 Abnormalities of speech such as dysarthria or nasal

speech may be associated

Oral pathology - poor teeth or poorly fitting dentures,

Loss of salivation - caused by medications, radiation, or

primary salivary dysfunction, recurrent bouts of
pulmonary infection should be rule out.
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 Zenkers diverticulum.

Finally, unexplained weight loss may be the only clue

to a swallowing disorder;
because of the difficulties

patients

avoid

eating

Causes of orophyryngeal dysphagia

Neuromuscular causes:
Amyotrophic lateral sclerosis
(ALS, Lou Gehrigs disease)
CNS tumors (benign or
malignant)
Idiopathic UES dysfunction
Manometric dysfunction of the
UES or pharynx
Multiple sclerosis
Muscular dystrophy
Myasthenia gravis
Parkinsons disease
Polymyositis or dermatomyositis
Postpolio syndrome
Stroke
Thyroid dysfunction

Structural causes:
Carcinoma
Infections of pharynx or

neck
Osteophytes and other
spinal disorders
Prior surgery or radiation
therapy
Proximal esophageal web
Thyromegaly
Zenkers diverticulum

 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
examination is
bolus in an
symptoms and

is normal with liquid barium, the

repeated after the patient is fed a solid
attempt to bring out the patients
thereby aid in localizing any pathology.

If the oropharyngeal portion of the study is normal, the

remainder of the esophagus should be examined.

This single test 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 or suprasternal notch or higher, even
though the bolus stops in the lower esophagus.
Esophageal dysphagia frequently can be relieved by

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.

Common causes of esophageal dysphagia

Motility (neuromuscular)
disorders:

Structural (Mechanical)

Primary

Intrinsic
Carcinoma and benign tumors
Diverticula
Eosinophilic esophagitis

Achalasia
Distal esophageal spasm
Hypercontractile (jackhammer)

esophagus
Hypertensive LES
Nutcracker (high-pressure)
esophagus
Other peristaltic abnormalities
Secondary
Chagas disease
Reflux-related dysmotility
Scleroderma and other

rheumatologic disorders

Disorders:

Esophageal rings and webs (other

than Schatzki ring)

Foreign body
Lower esophageal (Schatzki) ring
Medication-induced stricture
Peptic stricture
Extrinsic
Mediastinal mass
Spinal osteophytes
Vascular compression

 Patients who report dysphagia with solids and liquids are

more likely to have an esophageal motility disorder than

mechanical obstruction.
In patients who report dysphagia only after swallowing

solid foods and never with liquids alone, a mechanical

obstruction is suspected.
A luminal obstruction of sufficiently high grade, however,

may be associated with dysphagia for solids and liquids.

If food impaction develops, the patient frequently must

regurgitate for relief. If a patient continues to drink liquid

after the bolus impaction, large amounts of that liquid
may be regurgitated.

 In addition, hypersalivation is common during an

episode of dysphagia, thereby providing even more

liquid to regurgitate.
Episodic and nonprogressive dysphagia without weight

loss is characteristic of an esophageal web or a distal

esophageal (Schatzki) ring.
The patient notes that the bolus of food sticks in the

lower esophagus; it often can be passed by drinking

large quantities of liquids. The offending food
frequently is a piece of bread or steakhence the term
steakhouse syndrome.
Initially, an episode may not recur for weeks or

months,

but

subsequent

episodes

may

occur

If solid food dysphagia is clearly progressive, the differential

diagnosis includes peptic esophageal stricture and carcinoma.

Benign esophageal strictures develop in some patients with GERD.
Most of these patients have a long history of associated heartburn.
Weight loss seldom occurs in patients with a benign lesion, because

these patients have a good appetite and convert their diet to highcalorie soft and liquid foods to maintain weight.
Patients with carcinoma differ from those with peptic stricture in

several ways.

Diagnostic algorithm for patients with dysphagia

Odynophagia
Odynophagia, or painful swallowing, is specific for

esophageal involvement.
Range from a dull retrosternal ache on swallowing to a

stabbing pain with radiation to the back so severe that

the patient cannot eat or even swallow his or her own
saliva.
Reflects an inflammatory process that involves the

esophageal mucosa
esophageal muscle.

or,

in

rare

instances,

the

Associated with dysphagia, but pain is the dominant

complaint.

Causes of odynophagia
Caustic Ingestion
Acid
Alkali
Pill-Induced Injury
Alendronate and other

bisphosphonates
Aspirin and other NSAIDs
Emepronium bromide
Iron preparations
Potassium chloride (especially
slow-release form)
Quinidine
Tetracycline and its derivatives
Zidovudine

Infectious Esophagitis
Viral
Cytomegalovirus
EBV
HSV
HIV
Bacterial
Mycobacteria (tuberculosis or

Mycobacterium avium complex)

Fungal
Candida albicans
Histoplasmosis
Protozoan
Cryptosporidium
Pneumocystis
Severe Reflux Esophagitis
Esophageal Carcinoma

GLOBUS SENSATION
Globus sensation is a feeling of a lump or tightness in

the throat, unrelated to swallowing.

The sensation can be described as a lump, tightness,

choking, or strangling feeling, as if something is caught

in the throat.
Globus sensation is present between meals, and

swallowing of solids or large liquid boluses may give

temporary relief.
Frequent dry swallowing and emotional stress may

worsen this symptom.

PATHOPHYSIOLOGY AND
APPROACH

HICCUPS
The symptom of hiccups (hiccoughs, singultus) is caused by a

combination of diaphragmatic contraction and glottic closure.

Causes:
Idiopathic commonly
Associated with many conditions (trauma, masses, infections) that

affect the central nervous system, thorax, or abdomen, uremia.

Gastrointestinal: GERD, achalasia, gastropathies, and peptic ulcer.
After a large meal.
Because most cases are self-limited, intervention is not usually required.
The evaluation of chronic or difficult cases should include selected tests

to exclude esophageal, thoracic, or systemic diseases. Because GERD

has been associated with hiccups, a trial of acid suppressive therapy.
Treatment: chlorpromazine, nifedipine, haloperidol, phenytoin,

metoclopramide, baclofen, and gabapentin.

Alternative modalities, including acupuncture.

CHEST PAIN OF ESOPHAGEAL

ORIGIN
The esophagus and heart are anatomically adjacent and share

innervation hence, once cardiac disease is excluded, esophageal

disorders are probably the most common causes of chest pain.
Symptoms:
Esophageal chest pain usually is described as a squeezing or burning
substernal sensation that radiates to the back, neck, jaw, or arms.
Not always related to swallowing, the pain can be triggered by
ingestion of hot or cold liquids.
Awaken the patient from sleep and can worsen during periods of
emotional stress.
The duration of pain ranges from minutes to hours, and the pain may
occur intermittently over several days.
Can be severe, causing the patient to become ashen and to perspire,
it often abates spontaneously and may be eased with antacids.
Occasionally, the pain is so severe that narcotics or nitroglycerin are
required for relief.

 Gastroesophageal reflux may be triggered by exercise

and cause exertional chest pain that mimics angina

pectoris, even during treadmill testing.

Symptoms suggestive of esophageal origin include

pain that continues for hours, retrosternal pain without

lateral radiation, pain that interrupts sleep or is related
to meals, and pain relieved with antacids.

Pathophysiology and approach

Chest

pain that arises from the esophagus has

commonly been attributed to the stimulation of
chemoreceptors (by acid, pepsin, or bile) or
mechanoreceptors
(by
distention
or
spasm);
thermoreceptors (stimulated by cold) also may be
involved.

Gastroesophageal reflux causes chest pain primarily

through acid-sensitive
(see later).
Acid-induced

esophageal

dysmotility
esophageal pain.

may

be

chemoreceptors

cause

of

Heartburn and regurgitation

Heartburn (Pyrosis) is one of the most common GI

complaints.
Symptoms include indigestion, acid regurgitation, sour

stomact and bitter belching.

Study suggested that burning feeling rising from the

stomach or lower chest up toward the neck helps to

identify patient with gastroesophageal reflux.
Burning sensation often begins inferiorly and radiates

up the entire retrosternal area to the neck,

occasionally to the back, and rarely into the arms.
Heartburn due to gastroesophageal reflux of acid may

be relived, albeit only transiently, by ingestion of

Aggrevating factors :
Food: within one hour after heavy meal, sugars, chocolate, onions,

carminatives, and fatty foods may aggravate heartburn by decreasing

lower esophageal sphincter (LES) pressure.
Other foods: citrus products, tomato-based foods, and spicy foods

irritate the inflamed esophageal mucosa because of acidity or high

osmolarity. Beverages, including citrus juices, soft drinks, coffee, and
alcohol, also.
Activities: Activities that increase intra-abdominal pressure,

including bending over, straining at stool, lifting heavy objects, and

performing isometric exercises, running , stationary bike riding may
be a better exercise for those with GERD.

 Addiction: cigarette smoking as nicotine and air

swallowing relax LES pressure,

Emotions such as anxiety, fear, and worry lowering

visceral sensitivity thresholds

Drugs: exacerbate by reducing LES pressure and

peristaltic contractions (e.g., theophylline, calcium

channel blockers) or by irritating the inflamed
esophagus (e.g., aspirin, other nonsteroidal antiinflammatory drugs, bisphosphonates).

Symptoms:
Appearance of fluid in the mouth, either a bitter acidic material
or a salty fluid.
Regurgitation describes return of bitter acidic fluid into the
mouth and, at times, the effortless return of food, acid, or bilious
material from the stomach.
Regurgitation is more common at night or when the patient
bends over.
Water brash is an uncommon symptom that used to describe the
sudden filling of the mouth with clear, slightly salty fluid. This
fluid is not regurgitated material but is secreted from the
salivary glands as part of a protective, vagally mediated reflex
from the distal esophagus.
Absence of nausea, retching, and abdominal contractions.

PATHOPHYSIOLOGY AND
APPROACH
The reflux of gastric acid is most commonly

associated with heartburn, the same symptom

may be elicited by esophageal balloon
distention, reflux of bile salts, and acidinduced motility disturbances.
The pain mechanism is probably related to
the stimulation of mucosal chemoreceptors is
the sensitivity of the esophagus to acid that is
perfused into the esophagus or acid reflux,
demonstrated by monitoring of
pH.?????????????

Extraesophageal symptoms of
GERD
Caused by the esophageal motility disorders

associated with GERD

The classic reflux symptoms of heartburn and

regurgitation often are mild or absent

Extraesophageal manifestations of
GERD
Extraosephageal symptoms are
Asthma
Chronic cough
Excess mucus or phlegm
Globus sensation
Hoarseness
Laryngitis
Pulmonary fibrosis
Sore throat

Gastroesophageal reflux causes chronic cough and other

extraesophageal symptoms as a result of recurrent microaspiration

of gastric contents, a vagally mediated neural reflex, or in many
patients a combinationof both.
Bronchodilators reduce the LES pressure, most patient with asthama

have gastroesophageal reflux with or without bronchodilator therapy.

Symptoms that suggest reflux induced asthma induce the onset of

wheezing in adulthood in the absence of a history of allergies or

asthma, noctural cough or wheezing, worsening of asthma after
meals, by exercise, or in the supine position, and asthma that is
exacerbated by bronchodilators or is glucocorticoid dependent.
In patients with reflux, symptoms suggestive of aspiration include

nocturnal cough and heartburn, recurrent pnemonia, unexplained

fever and an associated esophageal motility disorder.

Ear, nose, and throat complaints associated with gastroesophageal reflux

include postnasal drip, voice changes, hoarseness, sore throat, persistent

cough, otalgia, halitosis, dental erosion, and excessive salivation.
Examination of the vocal cords may help in evaluating patients with

suspected acid refluxrelated extraesophageal problems.

Other complains include redness, hyperemia, and edema of the vocal cords

and arytenoids.
In severe cases, vocal cord ulcers, granulomas, and even laryngeal cancer,

all secondary to GERD

severe cases, vocal cord ulcers, granulomas, and even laryngeal cancer, all

secondary to GERD, but many experts favor an initial trial of acid

suppressive therapy with a PPI twice daily.

Algorithm for the approach to a patient with extraesophageal

manifestation of GERD, including noncardiac chest pain