Esophageal Motility Disorders in the Natural History of Acid-Dependent Causes of Dysphagia and Their Influence on Patients’ Quality of Life—A Prospective Cohort Study

Background: Esophageal dysmotility may be the cause or a secondary effect of gastric acid-dependent diseases: erosive reflux disease (ERD), Schatzki ring (SR) and eosinophilic esophagitis (EoE). Methods: This study aims to compare concomitant dysphagia with ERD, SR and EoE, considering manometric patterns, their role in the natural history and their impact on assessing quality of life. Fifty-eight patients with dysphagia underwent high-resolution manometry and esophago-gastro-duodenoscopy (EGD) with an assessment of SR, ERD and sampling for EoE, completed a questionnaire with the Eating Assessment Tool (EAT-10) and the Gastrointestinal Quality of Life Index. Based on endoscopic images and the histopathological criterion of EoE (≥15 eosinophils/high-power field), patients were assigned to groups with ERD, EoE, SR and with normal endoscopic and histopathological images. In the data analysis, p ≤ 0.05 was considered statistically significant. This trial was registered with ClinicalTrials.gov (no. NCT04803162). Results: Both EoE, SR and ERD correlate with ineffective motility. In ERD, normal peristalsis precedes the development of the disease, unlike EoE, which develops later and leads to absent contractility. The development of SR is associated with disorders of the upper esophageal sphincter (UES). In the group with SR and ERD, UES insufficiency significantly reduces the quality of life. Patients with normal esophagus in EGD scored the lowest quality of life and those with SR had the most severe dysphagia. Conclusion: The esophageal motility disorders co-occurring with endoscopic and histological anomalies do not significantly affect the severity of dysphagia, however, in the case of patients with ERD and SR and concomitant UES insufficiency, this motor dysfunction has a significant impact on the reduction in the patients’ quality of life. Although no specific esophageal motility pattern typical of EoE, ERD and SR has been identified, comparative assessment of manometric features may have a potential role in differential diagnosis.

Causes of upper gastrointestinal tract obstruction

Obstruction of the upper gastrointestinal tract, caused by blocked passage in the oesophagus, stomach or duodenum, is an important clinical and diagnostic problem in gastroenterological practice. The typical symptoms are dysphagia, postprandial vomiting, epigastric pain and weight loss. Post-inflammatory oesophageal lesions associated with reflux oesophagitis are the most common cause of obstruction. Other common causes include foreign bodies, neoplasms, chemical burns of the oesophagus and radiation-induced stenosis. In more than 2/3 cases, foreign bodies are localised in the proximal part of the oesophagus, but anatomical abnormalities, such as a Schatzki ring or post-inflammatory stenosis, increase the risk of food bolus impaction in the distal part of the oesophagus. Radiotherapy of head and neck tumours may cause stenosis, which affects more than 7% of patients treated this way. For the stomach and duodenum, 50–80% of obstruction cases are associated with neoplastic processes, with gastric cancer and pancreatic adenocarcinoma accounting for 35% and 15–25% of these cases, respectively. Mild causes of peripyloric obstruction include gastric and duodenal peptic ulcer, peritoneal adhesions, gastric polyps and Crohn’s disease. Symptoms of temporary pylorus obstruction can be caused by large, gastric hyperplastic pedunculated polyps. Therapeutic endoscopy is the most commonly used method for upper gastrointestinal tract obstruction. Depending on the cause, it involves foreign body removal, balloon enteroscopy, stenting with self-expanding metallic stents, and, in the case of treatment failure, surgical resection or palliative gastrojejunostomy.

Eosinophilic esophagitis: A potential complication of sublingual immunotherapy

Introduction. Eosinophilic esophagitis (EoE) represents chronic, a local immune-mediated disease with symptoms of esophageal dysfunction and histologically eosinophil-predominant inflammation and requires immediate endoscopy. Male gender is a strong risk factor. Case report. We presented a case of a 25-year-old young man with a history of allergic rhino-conjunctivitis, asthma, and intermittent severe feeding disturbance. The patient had begun sublingual immunotherapy therapy, containing specific soluble allergens for ambrosia. Six weeks after starting the ambrosia sublingual immunotherapy he developed burning epigastric pain, dysphagia, and odynophagia. Six days later, he was admitted to an emergency department due to choking on a solid of food. Esophageal histopathological findings were in favor of EoE. Sublingual immunotherapy was discontinued. He feels well now. Conclusion. The majority of cases of Eosinophilic esophagitis are diagnosed in spring or fall, 1-2 months following the peak of pollen season. Dysphagia, chest pain, food sticking, and bolus obstruction are the most common symptoms. Endoscopic findings are Schatzki ring, edema, exudates, furrows, and strictures. Six biopsies should be taken from areas with endoscopic mucosal abnormalities, and infiltration of eosinophils (more than 15 eosinophils/HRI) (HRI - high resolution imaging) is necessary for the diagnosis confirmation. Treatment options are proton pump inhibitors - oral dispersible tablets of budesonide or fluticasone propionate, an elimination diet. Sublingual immunotherapy should be discontinued. Family physicians should be aware of this complication in evaluating patients with dysphagia.

Dysphagia

Dysphagia may be oropharyngeal or esophageal. Evaluation is described, including a thorough dysphagia history of associated painful swallowing, location, solids versus liquids, intermittent versus progressive, acute versus gradual onset, and associated symptoms such as weight loss. Physical examination and key diagnostic tests are also reviewed. The evidence-based management of various etiologies of esophageal dysphagia are summarized. Motor disorders described include achalasia, the other primary esophageal motility disorders, and the most common secondary esophageal motility disorders. Esophageal diverticulae are also reviewed in this section. Mechanical esophageal obstruction is presented, including discussions of esophageal webs, rings, peptic stricture, and cancer. Important inflammatory and infectious causes of dysphagia are described, including caustic ingestion, eosinophilic esophagitis, and esophageal infections. The oral phases of liquid and solid swallowing are presented, as are the pharyngeal and esophageal phases of swallowing. Figures show the results of several diagnostic tests and other conditions, including pharyngeoesophageal diverticulum, giant epiphrenic diverticulum, Schatzki ring, and midesophageal squamous cell carcinoma. A flowchart outlines evaluation and management of dysphagia. This review contains 13 figures, 12 tables, and 68 references. Keyword: Esophageal cancer, Achalasia, Diffuse esophageal spasm, Esophageal ring, Peptic esophagitis, Eosinophilic esophagitis, Scleroderma, Esophageal stricture, Chagas disease, Stroke

Dysphagia

Dysphagia may be oropharyngeal or esophageal. Evaluation is described, including a thorough dysphagia history of associated painful swallowing, location, solids versus liquids, intermittent versus progressive, acute versus gradual onset, and associated symptoms such as weight loss. Physical examination and key diagnostic tests are also reviewed. The evidence-based management of various etiologies of esophageal dysphagia are summarized. Motor disorders described include achalasia, the other primary esophageal motility disorders, and the most common secondary esophageal motility disorders. Esophageal diverticulae are also reviewed in this section. Mechanical esophageal obstruction is presented, including discussions of esophageal webs, rings, peptic stricture, and cancer. Important inflammatory and infectious causes of dysphagia are described, including caustic ingestion, eosinophilic esophagitis, and esophageal infections. The oral phases of liquid and solid swallowing are presented, as are the pharyngeal and esophageal phases of swallowing. Figures show the results of several diagnostic tests and other conditions, including pharyngeoesophageal diverticulum, giant epiphrenic diverticulum, Schatzki ring, and midesophageal squamous cell carcinoma. A flowchart outlines evaluation and management of dysphagia. This review contains 13 figures, 12 tables, and 68 references. Keyword: Esophageal cancer, Achalasia, Diffuse esophageal spasm, Esophageal ring, Peptic esophagitis, Eosinophilic esophagitis, Scleroderma, Esophageal stricture, Chagas disease, Stroke