first time with a food bolus obstruction. 15 Endoscopic findings classically include longitudinal furrows, concen- |
symptoms and disease activity is often poor, and periodic endoscopic assessment may be needed, |
view in the hypopharynx and very proximal oesophagus. 15 Surgical options include a myotomy of the |
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tric mucosal rings and white plaques( see figure 7). 29 Diagnosis is confirmed via oesophageal mucosal biopsy |
especially if there are ongoing symptoms. 29 Dupilumab( an anti-interleukin-4 / 13 monoclonal anti- |
cricopharyngeus or diverticulectomy via open surgical or endoscopic approach. 5, 12 |
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demonstrating at least 15 eosinophils per high-power field. 29
Management strategies target symptom relief and prevent progres-
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body) has recently been approved by the US Food and Drug Administration for the management of eosinophilic oesophagitis, primarily in |
Schatzki’ s ring, oesophageal web
Schatzki’ s ring is a mucosal ring of the
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sion of disease. It is reasonable to pro- |
cases where budesonide is not toler- |
distal oesophagus— usually at or just |
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ceed with a trial of PPI therapy since some patients respond to PPIs even in the absence of reflux. 29, 30 The reason for this response to PPIs is unknown but could relate to reduced mucosal |
ated or is ineffective. The product is currently unavailable in Australia for this indication. 12
OPIOID-INDUCED OESOPHAGEAL
|
proximal to the LOS— causing luminal narrowing( see figure 9). 12 It can be either congenital or a consequence of reflux disease. 15 The condition is present in 7 % of the general popula- |
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permeability from reduced acid |
DYSMOTILITY |
tion, although it only causes signifi- |
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exposure.
Various approaches to an elimination diet have been studied. This is a common management strategy
|
Given the increasing prevalence of opioid prescribing, opioid-induced oesophageal dysmotility is becoming clinically more important. Opioids, |
cant dysphagia in a small minority. 15 It is present in 5-15 % of those with a sliding hiatus hernia. 6 Diagnosis can be made by either barium swallow or |
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adopted in children; however, the |
in the equivalent dose of 20mg a day |
endoscopy for direct visualisation. |
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same approach is mostly unsuccessful |
of morphine, can typically induce |
An oesophageal web is a mucosal |
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in adults because of a lack of adherence. 32 Three methods have been suggested. First, a targeted elimination |
oesophageal dysmotility that resembles either oesophagogastric outlet obstruction, achalasia or spasm and |
stricture that occurs elsewhere in the oesophagus and is usually congenital. These stenoses tend to cause only |
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diet of foods that have been identi- |
can lead to dysphagia. The condi- |
mild luminal narrowing; therefore, |
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fied by allergy testing or on patient |
tion can also occur with lesser doses |
they can present later in life, often |
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history. This has a success rate of less |
of opioids in those who are more |
after swallowing a large solid bolus. |
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than 50 %. 29 |
susceptible. |
Standard treatment for both con- |
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Second, the six-food elimina- |
The diagnosis is made by having |
ditions involves dilatation and treat- |
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tion diet, which involves avoidance |
a high index of suspicion and typi- |
ment of underlying reflux disease if |
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of foods commonly associated with |
cal features on manometry, together |
present. 15 |
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allergy, including milk, wheat, eggs, soy, nuts and seafood. The success rate with this method is between 50 % and 75 %. 14 Four-food and two-food elimination diets have also been tri- |
with normalisation of the dysmotility upon cessation of opioids. 9, 31
OESOPHAGEAL MALIGNANCY Most oesophageal cancers in West-
|
Figure 8. Zenker’ s diverticulum on barium swallow. |
CASE STUDIES
Case study one
DAVID, a 34-year-old teacher, presents
to ED with a food bolus obstruc-
|
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alled with reasonable success. Finally, the elemental diet substi- |
ern societies are adenocarcinoma. 32 This has been increasing in recent |
swallow may raise suspicion. 15 Treatment options and prognosis depend |
during swallowing( cricopharyngeal bar), which results in increased phar- |
tion. While eating a chicken kebab the night prior, he felt as if a mouthful |
tutes all food intake with liquid formula and can achieve a success rate of close to 90 % but is rarely tolerated by |
decades and probably reflects the increase in reflux disease, while the incidence of SCC has been wan- |
on the stage of the cancer but include endoscopic resection, surgery, chemoradiotherapy and pallia- |
yngeal pressures proximally, causing the outpouching. 12, 15 The condition tends to occur in the elderly because |
became lodged behind his sternum. He tried drinking liquids to encourage the bolus to pass, but he has since |
patients. 29 |
ing, which is potentially related to a |
tive stenting. 1 |
of age-related fibrosis and stiffening |
regurgitated all oral intake. He is spit- |
Pharmacotherapy is primarily focused on topical steroid therapy with gut-specific orally disintegrating budesonide. Response to treatment is |
15, 32 reduction in smoking. Patients tend to present late in the disease process when the tumour has already caused advanced steno- |
Other structural causes
ZENKER’ S DIVERTICULUM / PHARYNGEAL POUCH
|
of the cricopharyngeus. 15
The clinical presentation may include dysphagia that increases as the patient eats( once the pouch
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ting his saliva into an emesis bag and looking very uncomfortable.
He describes a few similar previous episodes, which he has managed
|
assessed with repeat endoscopy and biopsies after 12 weeks. 29 There is no current consensus on how long treat- |
sis of the oesophageal lumen, potentially with unexplained weight loss. The most sensitive method of diag- |
Zenker’ s diverticulum is an outpouching of the lumen in the upper oesophagus( see figure 8). This likely |
becomes full) and regurgitation of undigested food well after ingestion. Diagnosis is best made using |
at home by drinking fizzy drinks. He has never previously sought medical attention for this problem. His past |
ment should be continued. 29 |
nosis is by endoscopy; however, |
develops secondary to an inability of |
barium swallow and can be missed |
medical history is significant only |
The correlation between |
an obstructing lesion on barium |
the cricopharyngeus muscle to relax |
at endoscopy because of the limited |
for childhood eczema and seasonal |