Thanks to Aaron for a great case! This is an elderly patient coming in with chronic inability to swallow solid and liquids who was ultimately diagnosed with achalasia.
1) the approach to dysphagia should include asking whether the patient has odynophagia, globus sensation, red flags, and determining if the etiology seems to be orophayngeal vs esophageal and whether it is to solids or both solids and liquids 2) one way to think about the differential for esophageal dysphagia is to think about (1) motility (2) structural (intraluminal/ intrinsic vs extrinsic) and (3) functional 3) obtaining an EGD is both diagnostic and therapeutic for diagnosis of esophageal dysphagia, however, a barium swallow may be a good place to start if there is a risk for perforation
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Ddx Esophageal Dysphagia
Here is one approach to esophageal dysphagia:
1) Motility – eg achalasia, scleroderma, sjogren’s, nutcracker esophagus, esophageal spasm
- intraluminal or intrinsic i. food impaction ii. anatomic – web, diverticulum (eg Zenker), ring, stricture iii. infection – esophagitis (can also be eosinophilic, lymphocytic, radiation) iv. toxic/ corrosive – eg lye, ethanol, hydrogen peroxide v. malignancy vi. TE fistula
- extrinsic – eg vascular compression, mass
Bulbar symptoms/ cranial nerves
Recall the cranial nerve exam generally consists of: II – vision; III, IV, VI – PERRL, EOMI; V – sensation; VII – symmetric strength/ sensation; VIII – hearing; IX, X – soft palate, uvula; XI – trapezius/ SCM; XII – tongue
- cranial nerves IX, X, XII are implicated in bulbar symptoms and in problems with swallowing, gag reflex, hoarseness, tongue fasciculations, muscular wasting
- this is a rare condition from degeneration of ganglion cells in the myenteric plexus causing inability for the lower esophageal sphincter to relax
- the diagnosis is often delayed 2/2 thinking it is a functional condition
- it should be suspected in patients with dysphagia to solids and liquids, GERD unresponsive to PPIs, retained food in the esophagus
- Aaron found a great review article about Diagnosis and Management of Achalasia from the American Journal of Gastroenterology