Comprehensive Guide to Esophageal Disorders
Comprehensive Guide to Esophageal Disorders

Comprehensive Guide to Esophageal Disorders for Otolaryngology Board Examinations

Introduction

Esophageal disorders encompass a broad spectrum of conditions affecting the esophagus, the tube that carries food from the mouth to the stomach. This comprehensive guide provides insights into various esophageal disorders, their diagnosis, management, and treatment, tailored for otolaryngologists and medical students preparing for otolaryngology examinations.

Esophageal Motility Disorders

Esophageal motility disorders affect the movement of the esophagus and are prevalent in clinical practice. They include conditions such as achalasia, distal esophageal spasm (DES), and jackhammer esophagus. High-resolution manometry (HRM) is pivotal in diagnosing these conditions, with the Chicago Classification v4.0 providing a standardized diagnosis, allowing for tailored therapeutic approaches [Müller et al., 2022].

Achalasia

Achalasia is characterized by the inability of the lower esophageal sphincter to relax, leading to difficulty swallowing. Treatment options range from pneumatic dilatation, laparoscopic Heller myotomy with partial fundoplication, to peroral endoscopic myotomy (POEM), the latter being less invasive with comparable efficacy [Nurczyk & Patti, 2020].

Distal Esophageal Spasm (DES)

DES, a rare esophageal motility disorder, is associated with dysphagia and chest pain. Botulinum toxin injections and POEM have shown promise in symptom relief [Milito, Siboni & Bonavina, 2021].

Gastroesophageal Reflux Disease (GERD)

GERD, where stomach acid frequently flows back into the esophagus, is common. Extraesophageal symptoms like chronic cough, laryngitis, or sinusitis are prevalent. Treatment includes lifestyle changes, proton pump inhibitors, and sometimes prokinetic agents [Janiak, 2021].

Esophageal Necrosis

Acute esophageal necrosis, also known as black esophagus, is a rare form of mucosal injury, potentially due to microvascular occlusion. Treatment may involve supportive care, intravenous fluids, proton pump inhibitors, and sometimes surgery [Lechien et al., 2021].

Esophageal Disorders in Systemic Sclerosis

Systemic sclerosis, an autoimmune disease characterized by vasculopathy and tissue fibrosis, often involves the esophagus. High-resolution esophageal manometry should be considered in all patients with systemic sclerosis, as esophageal motility disorders were present in a significant majority of cases [Mascarenhas et al., 2023].

Treatment Approaches

For motility disorders like achalasia and DES, treatments such as botulinum toxin injections and POEM have shown efficacy. In GERD, lifestyle modifications and acid-reducing medications are effective. In cases of esophageal necrosis, supportive care and sometimes surgery are necessary [Costantini, Salvador & Costantini, 2021].

Laryngopharyngeal Reflux (LPR)

LPR, a variant of GERD, can present with various symptoms including chronic cough, laryngitis, and sinusitis. Treatment includes diet, proton pump inhibitors, and alginates, with the diagnosis often confirmed by 24-hour hypopharyngeal-esophageal impedance pH study [Lechien et al., 2021].

Conclusion

Esophageal disorders are diverse and require comprehensive knowledge for effective diagnosis and treatment. As research progresses, new insights and treatment approaches continue to emerge, improving care for patients with these disorders. This guide provides a thorough understanding of esophageal disorders, equipping otolaryngology professionals for board examinations and clinical practice.

Comprehensive Guide to Esophageal Disorders Questions
Comprehensive Guide to Esophageal Disorders Questions

FRCS ORL-HNS / Otolaryngology Board examinations Question for Comprehensive Guide to Esophageal Disorders:

Question 1

A 65-year-old patient presents with chronic cough and chest pain. High-resolution manometry reveals premature contractions. What is the most likely diagnosis?

A) Gastroesophageal reflux disease (GERD)
B) Achalasia
C) Jackhammer esophagus
D) Distal esophageal spasm (DES)
E) Inclusion body myositis

Answer: D) Distal esophageal spasm (DES)
Explanation: The patient’s symptoms and the presence of premature contractions on high-resolution manometry suggest a diagnosis of distal esophageal spasm (DES). DES is a rare esophageal motility disorder associated with dysphagia and chest pain, and it is characterized by premature contractions on high-resolution manometry

Question 2

A 70-year-old patient with a history of gastroesophageal reflux disease (GERD) presents with dysphagia and weight loss. What is the most likely diagnosis?

A) Achalasia
B) Distal esophageal spasm (DES)
C) Jackhammer esophagus
D) Inclusion body myositis
E) Barrett’s esophagus

Answer: A) Achalasia
Explanation: The patient’s long-standing history of GERD and the new onset of dysphagia and weight loss suggest a diagnosis of achalasia. Achalasia is a motility disorder characterized by defective peristaltic activity and impaired relaxation of the lower esophageal sphincter. It has been suggested that GERD might be one of the triggering factors leading to the development of achalasia.

Question 3

A 60-year-old patient presents with dysphagia and chest pain. High-resolution manometry reveals impaired relaxation of the lower esophageal sphincter. What is the most likely diagnosis?

A) Gastroesophageal reflux disease (GERD)
B) Distal esophageal spasm (DES)
C) Jackhammer esophagus
D) Type III achalasia
E) Inclusion body myositis

Answer: D) Type III achalasia
Explanation: The patient’s symptoms and the presence of impaired relaxation of the lower esophageal sphincter on high-resolution manometry suggest a diagnosis of type III achalasia. Type III achalasia, also known as spastic achalasia, is a subtype of achalasia characterized by impaired relaxation of the lower esophageal sphincter and spastic contractions in the esophageal body.

Question 4

A 75-year-old patient with systemic sclerosis presents with dysphagia. High-resolution manometry reveals a major disorder of esophageal peristalsis. What is the most likely diagnosis?

A) Gastroesophageal reflux disease (GERD)
B) Distal esophageal spasm (DES)
C) Jackhammer esophagus
D) Type III achalasia
E) Esophageal motility disorder associated with systemic sclerosis

Answer: E) Esophageal motility disorder associated with systemic sclerosis
Explanation: The patient’s history of systemic sclerosis and the presence of a major disorder of esophageal peristalsis on high-resolution manometry suggest a diagnosis of an esophageal motility disorder associated with systemic sclerosis. Esophageal disorders are often associated with systemic sclerosis, and these can be diagnosed and characterized by high-resolution esophageal manometry.

Question 5

A 50-year-old patient presents with dysphagia and weight loss. Videofluoroscopy reveals a cricopharyngeal bar. What is the most likely diagnosis?

A) Gastroesophageal reflux disease (GERD)
B) Distal esophageal spasm (DES)
C) Jackhammer esophagus
D) Type III achalasia
E) Inclusion body myositis

Answer: E) Inclusion body myositis
Explanation: The patient’s symptoms and the presence of a cricopharyngeal bar on videofluoroscopy suggest a diagnosis of inclusion body myositis. A cricopharyngeal bar, defined as marked protrusion with lacking relaxation and stricture of the upper esophageal sphincter on videofluoroscopy, is highly specific for inclusion body myositis.

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