Esophageal obstruction is caused by benign or malignant lesions within the lumen, wall or outside the wall of the esophagus. These lesions block the passage of food leading to dysphagia with consequent nutritional deficiencies. The diagnosis of the condition depends on history, clinical examination, esophagoscopy, and radiological investigations.
Presentation
Esophageal obstruction can be complete or partial and is caused by benign or malignant tumors or foreign bodies located within the lumen, wall (intramural) or outside the wall (extrinsic obstruction) of the esophagus. Intraluminal causes besides the above-mentioned etiologies include strictures secondary to corrosive ingestion, esophagitis (secondary to gastroesophageal reflux or infections) and esophageal webs which can be congenital or acquired. Intramural tumors can cause obstruction by narrowing the esophagus. Similarly, extrinsic factors like thyromegaly, cervical swellings, anomalous blood vessels (dysphagia lusoria), aneurysms of the aorta, left atrial enlargement, vertebral osteophytes, and malignant pulmonary tumors can compress the esophagus leading to obstruction of its lumen.
Patients present with progressively increasing dysphagia to either solids or liquids depending upon the etiology of the obstruction. In malignant lesions, the dysphagia to solids is the initial symptom, progressing to semi-solids and finally to liquids [1]. Anorexia, loss of appetite, weight loss, asthenia and nutritional deficiencies develop over a period of time. Drooling may be noticed if there is a complete luminal obstruction. This leads eventually to cachexia and influences the patient's quality and duration of life [2] [3]. The nutritional status in these patients determines the prognosis [4]. Patients with partial esophageal obstruction may have a sensation of food or foreign body getting stuck in the throat.
Entire Body System
- Hodgkin Lymphoma
The mediastinum is an uncommon location for presentation of peripheral T cell lymphoma. Esophageal involvement by non-Hodgkin's lymphoma is extremely unusual. [ncbi.nlm.nih.gov]
- Pseudotumor
The case illustrates the capacity of pseudotumor to behave in a locally aggressive manner and to present in extrapulmonic sites. [ncbi.nlm.nih.gov]
Gastrointestinal
- Dysphagia
All patients had an improvement in dysphagia of at least two dysphagia grades. The mean dysphagia grade fell from 3.15 to 0.62. Mean survival was 2.2 months. [ncbi.nlm.nih.gov]
Patients present with progressively increasing dysphagia to either solids or liquids depending upon the etiology of the obstruction. [symptoma.com]
- Odynophagia
Elderly patients are at especially at risk because they often have few teeth. [1] Odynophagia Partial obstruction of the esophagus can cause odynophagia. [1] Sialorrhea Sialorrhea refers to excessive accumulation of saliva, because patients cannot swallow [explainmedicine.com]
A blockage of the esophagus may cause a number of symptoms including discomfort or pain when eating and swallowing ( odynophagia ), difficulty swallowing ( dysphagia ) and regurgitation. [healthhype.com]
There may be pain or discomfort during eating and swallowing, a condition referred to as odynophagia. Difficulty in swallowing (technically known as dysphagia) may occur. In some cases, regurgitation of food may also occur. [phaa.com]
Case Report A 43-year old man presented to the emergency room with a one-day history of odynophagia and dysphagia. He had taken 3 tablets of nelfinavir obtained from his partner's medication cabinet in a suicidal attempt. [ispub.com]
[…] in throat Gagging Irritability Pain in neck, throat, or chest Recurrent aspiration pneumonia Respiratory distress Stridor Tachypnea or dyspnea Vomiting Wheezing TABLE 1 Symptoms of Esophageal Foreign Bodies Blood in saliva Coughing Drooling Dysphagia/odynophagia [aafp.org]
- Aphagia
A case report is presented of an 86-year-old man in a very poor general condition with a 10-year history of a Zenker's diverticulum as a cause of a complete obstruction of the esophagus with subsequent aphagia and massive cachexia. [ncbi.nlm.nih.gov]
- Gagging
[…] esophagorespiratory fistulae, diverticula, epithelial inclusion cysts. esophageal atresia congenital lack of continuity of the esophagus, commonly accompanied by tracheoesophageal fistula, and characterized by accumulations of mucus in the nasopharynx, gagging [medical-dictionary.thefreedictionary.com]
[…] moves up through a small opening into the chest— hiatal hernia Chronic inflammation in the esophagus—eosinophilic esophagitis Esophageal cancer or other tumors Symptoms Steakhouse syndrome may cause: Chest pain Difficulty swallowing Drooling Coughing, gagging [winchesterhospital.org]
[…] esophageal sphincter, pylorus, and ileocecal valve. 1, 2, 4 View/Print Table TABLE 1 Symptoms of Esophageal Foreign Bodies Blood in saliva Coughing Drooling Dysphagia/odynophagia Failure to thrive Fever Food refusal Foreign body sensation in throat Gagging [aafp.org]
- Early Satiety
These tablets undergo expansion in the stomach and are expected to cause early satiety. Patients with esophageal disorders should be cautioned against the use of this product because it may expand in the esophagus and create an obstruction. [ncbi.nlm.nih.gov]
Cardiovascular
- Chest Pain
Early (within 48 hours) procedure-related complications occurred in 4 of 13 patients and consisted of minor, transient chest pain that resolved within 6 hours (3 patients) and endoscopic stent dislodgment into the stomach (1 patient). [ncbi.nlm.nih.gov]
Patients experience diffuse retrosternal chest pain due to esophageal spasm and obstruction. [explainmedicine.com]
This causes chest pain and inability to swallow saliva. Attempts to relieve the obstruction by inducing vomiting at home are usually unsuccessful. Patients with complete esophageal obstruction can breathe and are not at risk of suffocation. [medicinenet.com]
- Retrosternal Chest Pain
Patients experience diffuse retrosternal chest pain due to esophageal spasm and obstruction. [explainmedicine.com]
Musculoskeletal
- Bone Pain
Other symptoms Other possible symptoms of cancer of the esophagus can include: Hoarseness Chronic cough Vomiting Hiccups Bone pain Bleeding into the esophagus. This blood then passes through the digestive tract, which may turn the stool black. [cancer.org]
Face, Head & Neck
- Neck Swelling
Esophageal perforation may result in neck swelling, crepitations, and pneumomediastinum. If perforation occurs in the stomach or intestines, fever and abdominal pain and tenderness may develop. [aafp.org]
Workup
The workup in a case of this disease includes history taking, complete physical and neurological examination, followed by laboratory tests, endoscopic evaluation, and imaging studies. Anamnestic data will provide information on the foreign body or caustic ingestion and details about the onset, duration, progress and degree of dysphagia. Physical examination will help detect nutritional abnormalities, thyromegaly, and cardiac or pulmonary etiology of the swallowing dysfunction. A thorough neurological examination is required to exclude neuromuscular causes of dysphagia.
Laboratory tests such as vitamin B12 levels, thyroid stimulating hormone levels (TSH) and creatine kinase should be ordered as part of the workup.
A plain X-ray chest may reveal a lung tumor or an enlarged left atrium compressing the esophagus. Non-invasive imaging studies like videofluoroscopy [5] and barium swallow help to diagnose mucosal and obstructive lesions while computed tomography and magnetic resonance imaging are required to delineate the extent of the obstructive growths and can also detect anomalous blood vessels.
Esophagoscopy is the gold standard test to detect the cause of the esophageal obstruction [6], to remove a foreign body, dilate a stricture or obtain tissue for histological evaluation.
If gastroesophageal reflux is suspected, then 24 hour pH monitoring will be required to diagnose the cause. Electromyography [7] and manometry can also be performed if indicated by history and physical examination findings.
X-Ray
- Esophageal Motility Disorder
[1,2] History of esophageal motility disorders Achalasia and other esophageal motility disorders can precipitate esophageal obstruction. [2] [explainmedicine.com]
foreign body lodgment; cause of obstructive bloat. esophageal hyperkeratosis hyperkeratotic thickening of the esophageal mucosa due usually to hypovitaminosis A or chlorinated naphthalene poisoning. esophageal motility disorders esophageal neoplasm [medical-dictionary.thefreedictionary.com]
Risk Factors Factors that may increase your chances of steakhouse syndrome: Not chewing your food completely Drinking too much alcohol Wearing dentures Having a physical problem that affects how food moves down the esophagus: Esophageal motility disorder [winchesterhospital.org]
Semin Thorac Cariovasc Surg 1999;11:326-36 70077-8/abstract)/ “Achalasia and esophageal motility disorders,” STS Patient Information, accessed 9-20-06. Rice TW, Baker ME. Midthoracic esophageal diverticula. [my.clevelandclinic.org]
Journal of neurogastroenterology and motility. Jul 2013;19(3):281-294. 3.Kahrilas PJ, Bredenoord AJ, Fox M, et al. The Chicago Classification of esophageal motility disorders, v3.0. [gi.dxy.cn]
- Cavitary Lesion
Repeat computer tomography scan of the chest after chemotherapy noted a significant decrease in the cavitary lesion in the right paraesophageal region and right mediastinum. [ncbi.nlm.nih.gov]
Treatment
The rates of reintervention were similar in both treatment groups, as were the 30-day mortality rates. [ncbi.nlm.nih.gov]
Prognosis
The nutritional status in these patients determines the prognosis. Patients with partial esophageal obstruction may have a sensation of food or foreign body getting stuck in the throat. [symptoma.com]
A more detailed subclassification of early esophageal cancer has been proposed for determining prognosis and selecting treatment. [clinicaladvisor.com]
Etiology
Patients present with progressively increasing dysphagia to either solids or liquids depending upon the etiology of the obstruction. [symptoma.com]
Etiology Large food bolus with no underlying cause Strictures or stenosis Carcinoma Shatzki’s ring (15% of people have fibrous stricture near GE junction) [scribd.com]
However, the etiology remains unknown in many cases. [acgcasereports.gi.org]
Clinical Take Home Point: Given the weak evidence for the benefits of glucagon, the potential side effect of nausea/vomiting, and the fact that nearly 1/4 th of patients will have an anatomic etiology to their obstruction, avoid the use of glucagon and [rebelem.com]
Acute esophageal syndromes In the table on the left are etiologies of an acute esophageal syndrome. Boerhaave syndrome Boerhaave syndrome is rupture of the esophageal wall. [radiologyassistant.nl]
Epidemiology
Esophageal food impaction: epidemiology and therapy. A retrospective study, observational study. Gastrointestinal Endoscopy. 2001;53:193-198. Gretarsdottir HM, Jonasson JG, Bjornsson ES. [appliedradiology.com]
"Esophageal food impaction: epidemiology and therapy. A retrospective, observational study". Gastrointestinal Endoscopy. 53 (2): 193–8. doi : 10.1067/mge.2001.112709. PMID 11174291. ^ a b c d Kerlin P, Jones D, Remedios M, Campbell C (2007). [en.wikipedia.org]
Pathophysiology
Conclusion Our understanding of the pathophysiology and treatment of achalasia has increased significantly. [hon.ch]
“Pathophysiology and treatment of Barrett's esophagus”. World J Gastroenterol. vol. 16. 2010. pp. 3762-72. Lagarde, SM, ten Kate, FJ, Richel, DJ. “Molecular prognostic factors in adenocarcinoma of the esophagus and gastroesophageal junction”. [clinicaladvisor.com]
Prevention
In 1 patient with an esophagorespiratory fistula, the prosthesis successfully occluded the fistula and prevented aspiration or pulmonary infection until the patient's death. [ncbi.nlm.nih.gov]
References
- Dakkak M, Hoare RC, Maslin SC, Bennett JR. Oesophagitis is as important as oesophageal stricture diameter in determining dysphagia. Gut. 1993;34:152–5.
- Javle M, Ailawadhi S, Yang GY, Nwogu CE, Schiff MD, Nava HR. Palliation of malignant dysphagia in esophageal cancer: a literature-based review. J Support Oncol. 2006;4:365–73.
- Fearon K, Strasser F, Anker SD, Bosaeus I, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2010;12:489–95.
- Miyata H, Yano M, Yasuda T, et al. Randomized study of clinical effect of enteral nutrition support during neoadjuvant chemotherapy on chemotherapy-related toxicity in patients with esophageal cancer. Clin Nutr. 2012;31:330–6.
- Splaingard ML, Hutchins B, Sulton LD, Chaudhuri G. Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil. 1988 Aug;69(8):637-40.
- Kumar VV, Amin MR. Evaluation of middle and distal esophageal diverticuli with transnasal esophagoscopy. Ann Otol Rhinol Laryngol. 2005 Apr;114(4):276-8.
- Ertekin C, Aydogdu I, Yüceyar N, et al. Electrodiagnostic methods for neurogenic dysphagia. Electroencephalogr Clin Neurophysiol. 1998 Aug;109(4):331-40.