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EN4.45 | Diseases of Oesophagus — SDL Guide (Part 2)

Diagnosis and Differential Diagnosis of Oesophageal Conditions

Constructing a systematic differential diagnosis for oesophageal disease requires a three-level framework: (1) pre-oesophageal (oropharyngeal) causes, (2) intrinsic oesophageal causes, and (3) extrinsic oesophageal compression. Mapping the patient's symptoms and examination findings to this framework guides targeted investigation. The distinction between mechanical obstruction and motility disorder is the first and most important clinical split: a structural lesion (carcinoma, stricture, foreign body, web) causes dysphagia to solids before liquids because solid food has a larger cross-sectional area and requires a patent lumen of adequate diameter to pass; a motility disorder (achalasia, diffuse oesophageal spasm) disrupts the peristaltic wave and impairs bolus propulsion regardless of its consistency, so the patient experiences difficulty with both solids and liquids from the onset. This single history question — 'Does liquid also stick?' — narrows the differential substantially before a single investigation is ordered. The temporal pattern adds further discriminatory power: progressive dysphagia over weeks (getting worse with each week) is carcinoma or peptic stricture until proven otherwise; episodic dysphagia that resolves spontaneously between attacks, often triggered by cold drinks or stress, points toward diffuse oesophageal spasm or a Schatzki ring.

Systematic differential framework for dysphagia:

Category	Key conditions	Distinguishing feature
Pre-oesophageal / oropharyngeal	Oral tumour, tonsil/pharyngeal tumour, neurological (bulbar palsy, MND, stroke)	Difficulty initiating swallowing, nasal regurgitation, aspiration at onset of swallow
Intrinsic — mucosal	Oesophagitis (reflux, candidal), Barrett's (rarely dysphagia alone)	Odynophagia, heartburn, endoscopy diagnostic
Intrinsic — mural obstruction	Carcinoma (SCC or adenocarcinoma), peptic stricture, Schatzki ring	Progressive dysphagia solids→liquids (malignancy); dysphagia intermittent for solids (ring/web)
Intrinsic — motility	Achalasia, diffuse oesophageal spasm	Dysphagia to solids AND liquids from onset; manometry diagnostic
Structural — pouch/diverticulum	Zenker's pharyngeal pouch	Regurgitation of undigested food, gurgling in neck, halitosis, risk of aspiration
Extrinsic	Retrosternal goitre, aortic aneurysm, mediastinal lymphadenopathy, lung tumour	Dysphagia without endoscopic mucosal abnormality; CT demonstrates extrinsic mass

Key diagnostic distinctions:

Carcinoma vs peptic stricture: Both cause progressive dysphagia on barium swallow, but carcinoma shows an irregular 'rat-tail' filling defect with mucosal destruction and shouldering; peptic stricture shows a smooth, tapered narrowing near the GOJ in a patient with long-standing GORD, and endoscopy confirms smooth mucosa over the stricture. Biopsy is mandatory to exclude carcinoma in any oesophageal stricture.

Squamous cell carcinoma vs adenocarcinoma: SCC occurs in the upper and middle thirds and is associated with tobacco, alcohol, achalasia, and Plummer-Vinson syndrome; adenocarcinoma is located in the lower third/GOJ, arises in Barrett's metaplastic epithelium, and is associated with GORD, obesity, and white male sex. This distinction has management implications because upper-third SCC is often treated with definitive chemoradiotherapy, while lower-third adenocarcinoma is more amenable to surgical resection.

Achalasia vs carcinoma at the GOJ: Both cause proximal oesophageal dilatation and a tapered lower oesophagus on barium swallow. In achalasia the tapering is smooth ('bird-beak', convex margins), the mucosa is intact on endoscopy, and manometry confirms the diagnosis. In carcinoma the narrowing is irregular, mucosal biopsy shows malignant cells, and there is no manometric signature of achalasia.

Oesophageal foreign body in children: The presentation depends on the object's nature and duration of impaction. A coin typically lodges at the cricopharyngeus (most common site in children) or the aortic arch level; the child drools, refuses feeds, and may have stridor from tracheal compression. A button battery impaction is indistinguishable from a coin on history but is differentiated on X-ray by its characteristic 'double-density' shadow with a halo sign (two layers of the battery visible). Button battery impaction is a surgical emergency.

Oesophageal atresia in neonates: Diagnosis is confirmed by failure to advance a wide-bore orogastric tube (Replogle tube) beyond 8–10 cm, with the tube coiling in the blind proximal pouch visible on a plain AP chest X-ray. A gasless abdomen confirms pure atresia without a distal TOF (type A); gas in the stomach and bowel indicates a distal TOF (type C — gas enters via the lower-segment fistula).

Management Principles for Oesophageal Diseases

Management of oesophageal diseases follows disease-specific principles that range from lifestyle modification (GORD) to emergency endoscopy (foreign body) to major oncological surgery (carcinoma). The key management principles for each major condition at the EN4.45 KH level are outlined below.

Management of GORD:
The treatment of GORD is stepwise. Lifestyle modifications form the foundation: weight loss, elevation of the head of the bed (30°), avoidance of late evening meals, reduction of dietary fat and alcohol, smoking cessation, and avoidance of precipitants (chocolate, peppermint, citrus, coffee). Pharmacological therapy uses proton pump inhibitors (PPIs) as the mainstay — they suppress gastric acid secretion by irreversibly blocking the H+/K+-ATPase pump; standard doses include omeprazole 20 mg, lansoprazole 30 mg, or pantoprazole 40 mg, given 30 minutes before the first meal. H2-receptor antagonists (ranitidine, famotidine) are less potent and used for milder symptoms. Antacids provide rapid but short-lived symptomatic relief. Helicobacter pylori eradication (triple therapy: PPI + amoxicillin + clarithromycin for 14 days) is recommended when H. pylori is detected, as it may worsen GORD and is associated with peptic ulcer disease. For refractory GORD or long-term PPI-intolerant patients, laparoscopic Nissen fundoplication (wrapping the gastric fundus 360° around the lower oesophagus to restore LOS competence) provides definitive surgical management.

Management of Barrett's Oesophagus:
All patients with Barrett's oesophagus require ongoing PPI therapy to suppress acid reflux and — at least in principle — slow metaplastic progression. Surveillance endoscopy is the cornerstone: non-dysplastic Barrett's requires endoscopy every 3–5 years; low-grade dysplasia (LGD) confirmed on two consecutive endoscopies 6 months apart requires 6-monthly surveillance or endoscopic ablation; high-grade dysplasia (HGD) requires endoscopic mucosal resection (EMR) or radiofrequency ablation (RFA). These endoscopic ablation techniques destroy the metaplastic epithelium and allow re-growth of normal squamous mucosa. Oesophagectomy is reserved for high-grade dysplasia/early adenocarcinoma not amenable to endoscopic resection.

Management of Oesophageal Carcinoma:
Staging determines treatment intent. T1-2N0M0 disease (early, localised) is potentially curative: surgical resection (oesophagectomy — Ivor Lewis procedure for mid/lower; three-stage McKeown oesophagectomy for upper) with curative intent, sometimes combined with neoadjuvant chemoradiotherapy (CROSS protocol: carboplatin + paclitaxel + radiotherapy) to downstage before surgery. For SCC of the upper third, definitive chemoradiotherapy (without surgery) is the preferred treatment because surgical access to the upper thoracic oesophagus carries high morbidity. For advanced (T3-4, N+, M+) or unresectable disease, palliative management includes self-expanding metallic oesophageal stenting (to restore swallowing), palliative chemotherapy, and radiotherapy. Nutritional support (nasogastric feeding, gastrostomy, or jejunostomy) is integral to oncological management.

Management of Oesophageal Foreign Bodies:
The immediate priority is establishing the site of impaction (barium swallow if not radio-opaque; plain X-ray if radio-opaque) and identifying the nature of the object. Sharp or pointed objects and button batteries require emergency removal regardless of site or symptoms. Flexible endoscopy under sedation suffices for smooth objects in the lower oesophagus. Rigid oesophagoscopy under general anaesthesia is preferred for objects in the upper third (at or just below the cricopharyngeus), large or fragile objects (dentures), and all button batteries. After removal, the oesophagus is inspected for mucosal tears, perforation signs, or a residual second foreign body. Suspicion of perforation (subcutaneous cervical emphysema, pneumomediastinum, surgical emphysema on X-ray, or worsening chest pain after removal) mandates immediate water-soluble contrast study and surgical consultation.

Management of Oesophageal Atresia:
Oesophageal atresia is a neonatal surgical emergency. At diagnosis, the neonate is kept nil by mouth; continuous suctioning of the upper oesophageal pouch via a Replogle tube prevents aspiration of pooled secretions; the baby is nursed semi-upright. Definitive treatment is surgical: primary anastomosis of the two oesophageal ends (with ligation and division of the TOF, if present) via a right extrapleural thoracotomy is performed as soon as the neonate is physiologically stabilised. If the gap is too long for primary anastomosis ('long-gap atresia'), a staged repair with gastrostomy feeding and delayed primary repair or colonic interposition is planned.

Self-Assessment: Diseases of the Oesophagus

Consolidate your understanding of oesophageal diseases by working through the following self-assessment scenarios and questions. Apply the clinical frameworks and management principles you have studied in this SDL. These questions are designed to test your ability to integrate anatomy, pathophysiology, investigation findings, and management principles across the range of oesophageal diseases covered in EN4.45. For each question, formulate your answer before reading the model answer — this active retrieval practice is the most effective method for consolidating clinical knowledge and identifying gaps. Pay particular attention to the anatomical facts (three oesophageal narrowings), the GORD-to-Barrett's-to-carcinoma premalignant sequence, the SCC-versus-adenocarcinoma distinction, and the two emergency scenarios (button battery impaction in a child; oesophageal atresia in a neonate) that require immediate recognition and action.

Short-answer questions:

1. Name the three natural anatomical narrowings of the oesophagus and state the vertebral level of each. Why are these clinically important?

1. A 50-year-old male presents with a 10-year history of heartburn and upper endoscopy reveals columnar metaplasia with goblet cells displacing the Z-line 4 cm proximal to the GOJ. (a) Name this condition. (b) What is the malignant risk? (c) Outline the surveillance and management strategy.

1. Differentiate squamous cell carcinoma from adenocarcinoma of the oesophagus under the following headings: location, predisposing factors, prognosis, and preferred treatment modality.

1. A 3-year-old child is brought to casualty with acute stridor and refusal to swallow after being found with a button battery from a television remote control. Chest X-ray shows a double-density circular opacity at the level of the aortic arch. (a) What is the diagnosis? (b) What is the timeframe for intervention and why? (c) What are the complications of delayed removal?

1. An infant born at term develops excessive salivation and cyanosis at the first breast feed. An orogastric tube cannot be passed beyond 9 cm. Chest and abdominal X-ray shows the tube coiling in the neck and gas throughout the GI tract. (a) Name the diagnosis and the Gross type. (b) What does the presence of GI gas indicate? (c) What is the immediate management?