Читать книгу The Esophagus - Группа авторов - Страница 22

Esophageal dysphagia is due to either a structural/mechanical obstruction or abnormal esophageal motility. Obstructive etiologies can be (i) benign or malignant, (ii) intrinsic or extrinsic, (iii) distal or proximal, and (iv) mucosal or intramural. Common mechanical causes of dysphagia are reflux‐induced strictures, rings, webs, esophageal or head and neck malignancy, or large hiatal or paraesophageal hernias. Inflammatory diseases such as eosinophilic esophagitis and lichen planus often present with luminal narrowing consistent with an obstructive phenotype. A rare but well‐described cause of long‐standing dysphagia is dysphagia lusoria, or extrinsic compression on the esophagus by an aberrant right subclavian artery. Patients with an anatomic cause of dysphagia typically have symptoms upon ingestion of solids and not liquids, and more likely with larger solids of a denser consistency. If the obstruction worsens and causes severe luminal narrowing, patients may develop dysphagia for both solids and liquids.

Patients with motility disorders often have dysphagia for both solids and liquids that progresses over time. Persistent, uninterrupted symptoms suggest peristaltic dysfunction such as in achalasia or systemic sclerosis, while intermittent symptoms may suggest esophageal spasm or ineffective motility. For patients with persistent symptoms suspected of having a motility disorder, associated symptoms often help in pointing toward a diagnosis. Achalasia patients often have associated regurgitation of undigested food, while patients with systemic sclerosis frequently have severe heartburn and, non‐uncommonly, reflux‐related distal esophageal strictures. For patients with intermittent symptoms, associated chest pain supports a diagnosis of esophageal spasm or jackhammer esophagus. This is usually absent in patients with ineffective esophageal motility. An algorithm for the evaluation of dysphagia is shown in Figure 1.1.