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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.

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]
  • 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]
  • 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 lungs[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]
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]
Progressive Dysphagia
  • A 47-year-old man suffered rapidly progressing dysphagia and complete esophageal obstruction secondary to extrinsic compression by mediastinal extension of a pancreatic pseudocyst.[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]
  • pain due to esophageal spasm and obstruction.[explainmedicine.com]
  • It can be accompanied by a feeling of discomfort in the chest, pain, srygivaniem and vomiting, gipersalivaciej, acidic or bitter belch, loss of body mass index.[omedicine.info]
Retrosternal Chest Pain
Asthenia
  • 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.[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]
  • 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]
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]
  • 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

  • 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]
  • 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

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: 2019-07-11 20:48