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Esophageal Obstruction

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.

Sepsis
  • […] patients (31%) and included stent migration (4 patients), food impaction (2 patients), membrane disruption with tumor ingrowth (1 patient), tumor overgrowth (1 patient), early pressure necrosis with hemorrhage (1 patient), and late pressure necrosis with sepsis[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]
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]
  • They may also suffer from chest pain, neck pain, regurgitation of food, or painful swallowing ( odynophagia ). [3] Patients with esophageal food boluses are also at risk of complications, such as perforation of the esophagus , and aspiration into the[en.wikipedia.org]
  • Presentation includes chest or throat discomfort, dysphagia or odynophagia, and difficulty managing oral secretions, such as choking and drooling, refusal to eat, vomiting, wheezing, blood-stained saliva, or respiratory distress, heartburn, cough, abdominal[appliedradiology.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]
Aphagia
  • Abstract 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]
  • In our case, we illustrate a giant right-sided Zenker's diverticulum responsible for complete aphagia in a 78-year-old male patient.[ncbi.nlm.nih.gov]
  • BACKGROUND AND AIMS: Total aphagia from complete esophageal obstruction (CEO) can be seen in patients with head-neck or thoracic malignancies undergoing chemoradiation or surgery.[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]
Failure to Thrive
  • Emesis and failure to thrive prompted a modified barium-swallow study, which revealed that the tracheostomy tube was causing an obstruction in the proximal esophagus.[ncbi.nlm.nih.gov]
Epigastric Tenderness
  • Physical examination was significant for epigastric tenderness and excessive salivation. Chest x-ray showed a posterior mediastinal fullness.[ncbi.nlm.nih.gov]
Chest Pain
  • Esophageal ulceration is a common sequelae of EVS with chest pain, stricture, and perforation occurring less frequently.[ncbi.nlm.nih.gov]
  • 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]
  • Nine complications occurred in eight patients (23%) and included chest pain that required analgesia (n 3), food impaction (n 1), stent migration (n 2), and upper gastrointestinal tract hemorrhage (n 3).[ncbi.nlm.nih.gov]
  • 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
Osteophyte
  • 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[symptoma.com]

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.

Esophageal Motility Disorder
  • motility disorders Achalasia and other esophageal motility disorders can precipitate esophageal obstruction. [2][explainmedicine.com]
  • motility disorders esophageal neoplasm very rare except for papilloma and fibropapilloma; causes chronic esophageal obstruction. esophageal obstruction acute obstruction is manifested by inability to swallow, regurgitation of saliva, food and water through[medical-dictionary.thefreedictionary.com]
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]
  • Baseline characteristics, changes in Mellow-Pinkas dysphagia score, and adverse events were collected and compared according to the presence and absence of additional palliative treatment.[ncbi.nlm.nih.gov]
  • Preoperative recognition of gastroesophageal intussusception may allow nonoperative reduction or treatment by minimally invasive surgery.[ncbi.nlm.nih.gov]
  • BACKGROUND: Effective surgical treatments for achalasia of the esophagus facilitate swallowing by division of muscles that fail to relax normally during swallowing.[ncbi.nlm.nih.gov]
  • Abstract BACKGROUND Esophageal variceal band ligation (EVBL) performed by esophagogastroduodenoscopy (EGD) is a routinely performed procedure for the treatment of esophageal varices that is undertaken to control bleeding and prevent further complications[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]

Etiology

  • Patients present with progressively increasing dysphagia to either solids or liquids depending upon the etiology of the obstruction.[symptoma.com]
  • Etiology and management of esophageal food impaction: a population based study. Scandinavian J Gastroenterol. 2015;50:513-518. American Society for Gastrointestinal Endoscopy.[appliedradiology.com]
  • 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]

Epidemiology

  • Barrett’s Espohagus gives an extensive overview covering epidemiology, screening, pathology, gastroenterology and surgery.[books.google.de]
  • 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]
Sex distribution
Age distribution

Pathophysiology

  • Conclusion Our understanding of the pathophysiology and treatment of achalasia has increased significantly.[hon.ch]

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]
  • Abstract BACKGROUND Esophageal variceal band ligation (EVBL) performed by esophagogastroduodenoscopy (EGD) is a routinely performed procedure for the treatment of esophageal varices that is undertaken to control bleeding and prevent further complications[ncbi.nlm.nih.gov]
  • If esophagocardiomyotomy is performed, a complementary antireflux procedure is mandatory to prevent postoperative gastroesophageal reflux.[ncbi.nlm.nih.gov]
  • The addition of a membrane might prevent tumor ingrowth and allow treatment of digestive-respiratory fistulas. We report the clinical experience with a prototype silicone membrane-covered self-expanding metal stent.[ncbi.nlm.nih.gov]
  • The aims of the present study were 1) to investigate GIT growth and maturation during the last 20% of gestation in pigs (term 114 /- 2 d), and 2) to investigate the effect of esophageal ligation, to prevent fetal swallowing, at 80% to 91% gestation.[ncbi.nlm.nih.gov]

References

Article

  1. Dakkak M, Hoare RC, Maslin SC, Bennett JR. Oesophagitis is as important as oesophageal stricture diameter in determining dysphagia. Gut. 1993;34:152–5.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. Kumar VV, Amin MR. Evaluation of middle and distal esophageal diverticuli with transnasal esophagoscopy. Ann Otol Rhinol Laryngol. 2005 Apr;114(4):276-8.
  7. Ertekin C, Aydogdu I, Yüceyar N, et al. Electrodiagnostic methods for neurogenic dysphagia. Electroencephalogr Clin Neurophysiol. 1998 Aug;109(4):331-40.

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Last updated: 2018-06-22 00:00