Diseases of the Esophagus

Key complaints and pain syndrome

The basis for diagnosing esophageal diseases lies in a thorough analysis of the patient's subjective sensations. The main complaints are dysphagia (difficulty with food propulsion) and odynophagia (pain on swallowing).

Pain in esophageal pathology is localized predominantly retrosternally. The pain can be constant or paroxysmal, and its radiation—to the shoulder, neck, back, or left hemithorax—surprisingly accurately mimics an angina attack. The difficulty in differential diagnosis lies in the fact that esophageal spasm can be completely relieved by taking nitroglycerin, just like cardialgia.

The main causes of retrosternal pain of esophageal origin are:

• Esophageal spasm.
• Gastroesophageal reflux disease (GERD).
• Esophageal wall rupture.
• Hiatal hernia.
• Achalasia cardia and neoplasms (cancer).

The clinical picture is often complemented by dyspeptic phenomena. Heartburn, which is a burning sensation in the epigastrium radiating upwards, occurs due to pathological reflux of acidic gastric contents. Regurgitation (sudden exit of gases or a small volume of contents into the mouth), hiccups, and nausea are also part of the dyspeptic syndrome structure. Halitosis (halitosis) can also be a characteristic symptom. Bleeding is significantly less common than in lesions of the stomach or duodenum.

Detailed characteristics of dysphagia

Dysphagia is a disorder of swallowing and physical passage of the food bolus. Depending on the level and mechanism of the lesion, several clinical variants are distinguished:

1. Pharyngeal dysphagia. The very process of swallowing initiation is impaired. Most often this is a consequence of neuromuscular disorders. Clinically manifested by difficulty at the very moment of swallowing, accompanied by agonizing choking and coughing.
2. Esophageal dysphagia. Differs in clear dynamics of deterioration. In the initial stages, the patient has difficulty swallowing only solid food, but as the process progresses, the passage of liquids is also impaired.
3. Pseudodysphagia. The subjective sensation of a "lump in the throat" (globus hystericus), which is physically unrelated to the act of swallowing. Often of hysterical nature or a reflex reaction of the body in heart diseases and cholelithiasis.

Key etiological factors of true dysphagia include organic strictures (post-burn scars, tumors), motility disorders (achalasia cardia), neurological deficits (bulbar and pseudobulbar syndromes), as well as systemic connective tissue diseases (systemic sclerosis).

Esophageal vomiting and physical examination

Esophageal vomiting stands out as a specific and extremely alarming symptom of severe obstruction (in strictures or tumors). The mechanism of its development is simple: food accumulates above the stenosis zone and is retrogradely ejected outward under the action of antiperistalsis.

Differential distinctions from gastric vomiting:

• Complete absence of preceding nausea.
• Presence of a clear precursor: the sensation of the bolus "getting stuck" behind the sternum.
• Composition of the vomitus: it contains exclusively undigested food.

If there is an admixture of blood in the masses, this indicates the breakdown of a malignant tumor, deep trauma to the mucous membrane, or a dangerous rupture of varices.

Physical examination (palpation, percussion) of the organ itself is uninformative. The physician focuses on assessing the general status. Attention is drawn to a sharp weight loss up to severe cachexia due to nutritional insufficiency (typical for cancer and achalasia). An active search for signs of systemic sclerosis is also carried out: an expressionless face and areas of skin induration. Prolonged stenoses lead to pathomorphological changes—the formation of a suprastenotic dilation (stretching of the esophagus above the narrowing) invisible upon inspection.

Instrumental diagnostics

Confirmation of the diagnosis rests entirely on instrumental research methods:

• Radiological method. A baseline procedure using a contrast suspension (barium sulfate). The swallowing test makes it possible to assess the motility of the organ, study the mucosal relief, and determine the contours of the esophagus (identify narrowing, deformations, and suprastenotic dilations).
• Esophagoscopy (as part of FEGDS). The most sensitive diagnostic method. Endoscopy allows visual assessment of the mucosal state and biopsy taking from suspicious foci for histological and bacteriological analysis. In case of bleeding, the method is indispensable for emergency indications, as it helps to accurately verify the source (varices, cancer).
• 24-hour pH monitoring. Used for functional assessment, diagnosis of GERD and differentiation of retrosternal pain, as well as for quality control of antisecretory therapy. The criterion for reflux is considered to be a drop in intraesophageal pH below 4.0. If in a healthy person the time of such "acidification" is less than an hour per day, then in GERD it increases from 4 to 14.5 hours, occupying up to 60% of the day's time.

Class and exam questions

What else to study on this topic

• Gastroesophageal reflux disease (GERD)
• Achalasia cardia: etiology and pathogenesis
• Esophageal varices
• Systemic sclerosis and its impact on the gastrointestinal tract
• Differential diagnosis of retrosternal pain

Other topics in the "Digestive System" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.