49.
Potential causes of oesophageal dysphagia are listed in Table 17.1 Key points in the history include whether dysphagia is for solids or liquids, whether it is intermittent or progressive, and whether there are associated reflux symptoms such as heartburn.30 Progressive difficulty in swallowing solids is suggestive of a structural lesion, while dysphagia for both liquids and solids is associated with motility disorders. Endoscopy provides a means to visualise and biopsy structural lesions and may also be therapeutic (for example, dilatation of a peptic stricture). Endoscopy and biopsy are also likely to be helpful when odynophagia (painful swallowing) is the presenting complaint, and in the patient with dysphagia can help exclude eosinophilic esophagitis, which is increasingly being recognised even in older patients.31 Barium videofluoroscopy provides complementary information regarding motor function as well as structural lesions, while manometry is of greatest use in confirming or excluding a diagnosis of achalasia.
Table 17.1 Oesophageal causes of dysphagia.
| Structural lesions |
| Neoplasm |
| Peptic stricture |
| Rings and webs |
| Vascular compression |
| Pill esophagitis |
| Reflux esophagitis |
| Eosinophilic esophagitis |
| Diverticula |
| Motility disorders |
| Achalasia |
| Distal oesophageal spasm and jackhammer oesophagus |
| Non‐specific motility disorders |
| Systemic disease (diabetes mellitus, progressive systemic sclerosis, Parkinson’s disease) |
Of the primary oesophageal motility disorders, the proportions of patients in different categories are similar in older (>60 years) and younger patients; but in older patients presenting with dysphagia, achalasia and distal oesophageal spasm are more commonly diagnosed in the older group.20 While the peak incidence of achalasia is in early to mid‐adulthood, a second, smaller peak occurs in the elderly.32 Oesophageal spasm is more commonly diagnosed over 50 years of age, while non‐specific motility disorders are particularly associated with an older population.
Achalasia
Achalasia is an oesophageal motor disorder of unknown aetiology, associated with incomplete or absent swallow‐induced LOS relaxation together with disordered oesophageal contractile activity.33 Inflammation of the myenteric plexus is an early histological finding, followed by ganglion loss and neural fibrosis. The condition typically presents with dysphagia for both liquids and solids, although weight loss, regurgitation, and aspiration may also be presenting symptoms, particularly in the elderly. Conversely, chest pain is reported less often in older than in young patients.
A barium swallow may show impaired peristalsis, delayed emptying, and dilatation of the oesophageal body (the latter more characteristic in the elderly than the young), with ‘bird’s beak’ or ‘rat’s tail’ tapering at the LOS (Figure 17.2). At manometry, the resting LOS pressure may be high or within the normal range, but LOS relaxation on swallowing is either absent or incomplete. Contractions of the oesophageal body can be either absent (type I) or simultaneous (type II), or there may be premature distal oesophageal contractions (type III)33 (Figure 17.3). Endoscopy (and sometimes endoluminal ultrasound and/or computed tomography) must be performed to exclude ‘pseudo‐achalasia’, especially in the elderly; this entity presents with features of achalasia but is due to carcinoma of the distal oesophagus or cardia. A short history of symptoms and disproportionate weight loss is particularly suggestive of this diagnosis.
Figure 17.2 Barium swallow in a patient with achalasia, demonstrating a dilated oesophagus with tapering at the distal end.
Pneumatic dilatation and surgical myotomy (now usually performed laparoscopically) represent the most efficacious treatments for achalasia, and each has a very high rate of treatment success in type 1 and 2 achalasia. Each is associated with a 1% perforation rate even in experienced hands; and while pneumatic dilatation is associated with less morbidity and cost, it may need to be repeated.34 In recent years, the technique of peroral endoscopic myotomy (POEM) has emerged and may allow close calibration of myotomy to the manometric findings – a useful asset in the treatment of type 3 achalasia, which should otherwise be managed laparoscopically.33 In general, either pneumatic dilatation or laparoscopic myotomy is well tolerated in the elderly; in a consecutive series of 51 patients age ≥65 undergoing the latter procedure, there were no deaths, few complications, and a median hospital stay of 3 days.35 Both pneumatic dilatation and POEM can induce reflux symptoms in a minority; this can be pre‐empted with laparoscopic myotomy by performing an anti‐reflux procedure concurrently.
For the frail elderly patient with achalasia, endoscopic injection of botulinum toxin into the LOS represents an alternative and safe therapy. Two‐thirds report improvement in dysphagia after this procedure, although the majority relapse within one year, and repeat treatments become progressively less effective.33 Pharmacological therapy to reduce LOS pressure (nitrates, calcium channel antagonists, or phosphodiesterase type 5 inhibitors) is of limited efficacy (possibly even less in the elderly than the young), requires frequent dosing, and is associated with frequent adverse effects, so it cannot be recommended.
Patients with achalasia have an increased risk (estimated as 16‐fold) of squamous cell carcinoma of the oesophagus, but as the absolute risk is small, the cost‐benefit ratio of surveillance endoscopy appears unlikely to be favourable.36 Occasionally, patients with achalasia have persistent dysphagia despite therapy, together with a tortuous, dilated oesophagus that empties poorly; in these circumstances, esophagectomy may be required.
Distal oesophageal spasm and ‘jackhammer’ oesophagus
These disorders are diagnosed in a minority of patients with dysphagia or chest pain, and in many cases, the relationship between symptoms and motor abnormalities is unclear. Distal oesophageal spasm (formerly termed diffuse) is characterised by the presence of simultaneous or premature pressure waves in the distal oesophagus18 (Figure 17.4). A barium swallow may show segmentation of contrast by contractions (a corkscrew appearance) in a minority of patients (Figure 17.5) but lacks sensitivity or specificity for diagnosing the disorder. Similar manometric abnormalities may occur in GORD and in association with diabetes mellitus, alcohol abuse, amyloidosis, and progressive systemic sclerosis. Hypercontractile, or ‘jackhammer’ oesophagus, is defined by high‐amplitude oesophageal pressure waves, but peristalsis is maintained and appears normal on the barium swallow. The management of both distal spasm and jackhammer oesophagus is discussed below in relation
