Causes of dysphagia

• Extrinsic mechanical
  • Carcinoma of the bronchus
  • Thoracic aortic aneurysm
  • Goitre
• Intrinsic mechanical
  • Benign stricture
  • Oesophageal carcinoma
  • Bolus obstruction
• Primary neuromuscular
  • Achalasia
  • Diffuse oesophageal spasm
  • Nutcracker oesophagus
• Secondary neuromuscular
  • Multiple sclerosis
  • Systemic sclerosis
  • Chagas' disease
  • Autonomic neuropathy

Investigation of dysphagia

• History and examination may suggest underlying pathology
• Consider the following investigation
  • Upper GI endoscopy
  • Barium swallow
  • Endoscopic ultrasound
  • Oesophageal manometry
  • CT or MRI scan

Achalasia

• Due to reduced number of ganglion cells in myenteric plexus
• Vagi show axonal degeneration of the dorsal motor nucleus and nucleus ambiguous
• Aetiology is unknown but a neurotropic virus may be important
• Similar to Chagas' disease due to Trypanosoma Cruzi

Clinical features

• Commonest in patients between 40 - 70 years
• Male : female ratio is approximately equal
• Symptoms include dysphagia, weight loss, regurgitation, chest pain
• 5% of patients develop squamous carci
• noma

Investigations

• CXR - widening of mediastinum, air / fluid level and absence of gastric fundus gas bubble
• Barium Swallow - dilatation & residue, small tertiary contractions and 'rat tail' of distal oesophagus

• Manometry - absent primary peristaltic wave and non-propulsive tertiary contractions
• Endoscopy - essential to exclude 'pseudoachalasia' due to submucosal carcinoma
• Tight lower oesophageal sphincter which relaxes with gentle pressure usually seen
• Isotope transit studies

Differential diagnosis

• Diffuse oesophageal spasm
• Infiltrating carcinoma
• Hypertrophic lower oesophageal sphincter
• Scleroderma
• Chagas' disease

Treatment options

• Two treatment options are commonly available
• Treatment selected should be based in individual patient needs

Balloon Dilatation

• Rider Moeller Balloon
• Inflated to 300 mmHg for 3 minutes
• 3% perforation rate
• 60% dysphagia free at 5 years
• May be repeated if necessary

Cardiomyotomy

• Described by Heller (1914) & Grenveldt (1918)
• May be performed laparoscopically
• 85% will have an improvement in symptoms
• 10% develop oesophageal reflux
• 3% will develop and oesophageal stricture
• Some combine cardiomyotomy with an antireflux operation

Bibliography

Banerjee S. Achalasia of the cardia. Hospital Update Sep 1993. 480 - 488.
Hunt D R, Wills V L. Laparoscopic Heller Myotomy for achalasia. Aust NZ J Surg 2000; 70: 582-586.
Hunter J G, Richardson W S. Surgical management of achalasia. Surg Clin N Am 1997; 77: 993-1115.
Lamb P J, Griffin S M, Beckingham I J. Controversial topics in surgery. Achalasia of the cardia - dilatation or division? Ann R Coll Surg Engl 2006; 88: 9-12
Leslie P, Carding P N, Wilson J A. Investigation and management of chronic dysphagia. Br Med J 2003; 326: 433-436.
Navaratnam R M, Clayman C, Winslet M C. Clinical advances in the evaluation of oesophageal disease. Hosp Med 2000; 64: 194-199