Table of Contents
Overview
Dysphagia refers to difficulty swallowing and is a key symptom encountered in various upper GI pathologies. It can be caused by mechanical obstruction or neuromuscular dysfunction and is commonly assessed in clinical settings due to its association with conditions like oesophageal cancer, strictures, and achalasia.
Achalasia, in contrast, is a specific diagnosis involving oesophageal aperistalsis and failure of the lower oesophageal sphincter to relax. Understanding the differences in presentation and cause is crucial for final-year medical students preparing for exams and clinical decision-making.
Dysphagia
Definition
“Difficulty swallowing”
— Not to be confused with Odynophagia = painful swallowing
Sites of Dysphagia
- Oropharyngeal – difficulty initiating a swallow
- Oesophageal – food ‘sticking’ mid-chest
- Gastro-oesophageal – delayed entry into stomach
- Para-oesophageal – extrinsic compression (e.g., masses)
Clinical Clues & Differentials
| Presentation | Likely Cause |
|---|---|
| Solids only | Mechanical obstruction (e.g., stricture, carcinoma) |
| Solids & liquids | Motility disorder (e.g., achalasia, vagus nerve dysfunction) |
| Liquids only | Pharyngeal disorder (e.g., globus pharyngeus) |
Achalasia
Aetiology
- Idiopathic (majority of cases)
- Possible factors:
- Autoimmune
- Neurodegenerative (loss of myenteric plexus neurons)
- Post-viral inflammation
Pathogenesis
- Vagus nerve or myenteric plexus dysfunction
- Leads to:
- Aperistalsis of oesophageal body
- Impaired relaxation of lower oesophageal sphincter (LES)
Clinical Features
- Progressive dysphagia to both solids & liquids from onset
- Chest pain due to oesophageal spasms
- Reflux, especially nocturnal → risk of aspiration pneumonia
- Regurgitation of undigested food
Key Investigations
- Barium Swallow
- Classic “bird-beak” appearance of LES
- Oesophageal Manometry
- Confirms aperistalsis and high LES tone
- Upper GI Endoscopy
- To exclude malignancy (“pseudoachalasia”)
Management
Note: Current treatments are palliative, not curative.
- Balloon dilation (pneumatic) of LES
- Botulinum toxin injection (temporary)
- Heller myotomy (surgical muscle cutting) ± fundoplication
- POEM (Per-Oral Endoscopic Myotomy) – newer, minimally invasive
- Lifestyle/dietary adjustments (small frequent meals, upright eating)
Summary – Dysphagia & Achalasia
Dysphagia and achalasia are high-yield topics with significant clinical implications. Dysphagia serves as a key red-flag symptom that must be thoroughly evaluated, while achalasia is a distinct motility disorder characterised by LES dysfunction and oesophageal aperistalsis. Diagnostic clarity is essential, often requiring barium swallow, manometry, and endoscopy. Management is typically palliative but effective. For a broader clinical context, see our Gastrointestinal Overview.