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Dysphagia
James C. Reynolds and Bassem R. George
Questions and Answers
C.Diffuse esophageal spasm (DES)
D.Peptic stricture
1. Which one of the following systemic disorders is often associated with dysphagia and demonstrates a pattern of IEM?
A.Progressive systemic sclerosis
B.Amyotrophic lateral sclerosis
C.Parkinson’s disease
D.Hyperthyroidism
Answer: A
Answer: A
IEM is characterized by low-amplitude contractions, lowpressure LES, and intermittent dropped or non-peristaltic
contractions. These manometric findings are common in
patients with severe esophageal reflux and are also characteristic of the findings seen in systemic sclerosis.
Amyotrophic lateral sclerosis (Lou Gehrig disease) and
Parkinson’s disease most commonly present with transfer
dysphagia. Esophageal involvement is not uncommon,
however, and includes nonspecific motility changes
including simultaneous contraction and dropped
peristalsis.
2. A 65-year-old teacher is evaluated for a 2-year history of
progressive dysphagia initially intermittent but subsequently to both solids and liquids. She has a feeling of
chest tightness associated with regurgitation of undigested
food. She has had a 12 lb weight loss in the past year. On
physical examination, the patient appears uncomfortable;
she is thin and afebrile; the blood pressure is 140/90 mmHg,
the pulse rate is 92/min, and the respiration rate is 20/min.
Her BMI is 21.
Barium esophagography revealed a dilated esophagus
with an air/fluid level and tapered narrowing of the distal
esophagus. Endoscopy shows a dilated esophagus with
retained food and a tight lower esophageal sphincter.
Which of the following is the most likely diagnosis?
A.Achalasia
B.Scleroderma
The patient’s history is typical for achalasia. The barium
study and endoscopic appearance described are typical for
achalasia, but the diagnosis should be confirmed manometrically with esophageal motility studies. The manometric diagnosis of achalasia usually includes an elevated
LES pressure, failure of the LES to relax with swallowing, and diminished or absent peristalsis of the esophageal
body. Peptic stricture and DES do not cause esophageal
dilation. Scleroderma that is complicated by a stricture
may be hard to differentiate from achalasia. Scleroderma
patients may manifest associated features such as
Raynaud’s phenomenon and long-standing heartburn.
3. A 72-year-old Caucasian male who presented with food
impaction but has an esophagus that appears normal by
endoscopy is most likely to be suffering from which of
the following esophageal disorders?
A.Esophageal stricture
B.Barrett’s esophagus
C.Eosinophilic esophagitis (EoE)
D.Candida esophagitis
Answer: C
EoE has recently become the most common cause of food
impaction and hence it is extremely important to consider
this condition in the differential diagnosis. EGD with
­biopsies from the mid-esophageal region is crucial to
make the diagnosis. Circular rings may be visible in the
esophagus on endoscopy (feline esophagus or trachealization of the esophagus). There is increased risk of perforation in such patients with vomiting and forceful
dilation. Candida esophagitis and Barrett’s esophagus
should be easily recognized endoscopically. Esophageal
stricture can be missed by both endoscopy and barium
swallow. The diagnosis can be confirmed by swallowing
C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology,
DOI 10.1007/978-1-4419-1623-5_29, © Springer Science+Business Media, LLC 2012
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radio opaque solid substance like marsh mellow.
Alternatively a therapeutic trial of dilation can be performed once EoE has been excluded.
4. A 68-year-old patient is noted to have choking during
feeding. A “dysphagia consult” reveals aspiration with
thin liquids. Further evaluation is likely to reveal that this
finding is due to
A.Achalasia
B.Pseudobulbar palsy
C.Epiphrenic diverticula
D.EoE
J.C. Reynolds and B.R. George
Answer: B
All muscles involved with the transfer of oral contents to
the esophagus are striated and under the control of cranial
nerves. Brain stem disease commonly causes dysphagia.
Pseudobulbar palsy and prior CVAs are the most common
neurological causes of transfer dysphagia leading to aspiration. Achalasia is one of the most important primary disorders of esophageal motility and hence it does not play a
role in transfer dysphagia or aspiration. EoE and diverticula may lead to solid food dysphagia but not aspiration.