Neoplasms are a common cause of transfer and transport dysphagia. Ihe esophagus or surrounding structures may be the primary site. Esophageal cancer is diagnosed in about 10,000 people a year in the United States. About the same number die from the disease each year as well. Ninety-five percent of esophageal neoplasms are squamous cell; the remaining 5 percent are adenocarcinomas. Men are affected three times as often as women. Risk factors for squamous cell disease includes alcohol, smoking, achalasia, and previous caustic ingestion with lye. Barrett's esophagus predisposes to adenocarcinoma, which has shown an increase in incidence in recent years.8 Ihere is usually a fairly rapid progression of dysphagia from solids to liquids (6 months). In addition to dysphagia, patients with neoplasm may present with bleeding. Early diagnosis impacts outcome, and for this reason the emergency physician should assume a neoplastic cause in patients over age 40 who present with new-onset dysphagia. Ihese patients need an expedient workup to rule out malignancy. Definitive diagnosis is made by endoscopy with biopsy. Survival is dismal: the median is less than 1 year.
Esophageal stricture occurs as a result of scarring from GERD or other chronic inflammation. Generally they occur in the distal esophagus, proximal to the gastroesophageal (GE) junction. Strictures may interfere with LES function. Symptoms may build over years and are often noted solely with solids. Stricture can serve as a barrier to reflux, so heartburn may decrease as dysphagia increases. Workup involves ruling out malignancy and treatment is dilatation. 9
Schatzki's ring is the most common cause of intermittent dysphagia with solids. Ihis fibrous, diaphragm-like stricture near the GE junction is present in up to 15 percent of the population, the majority of whom are asymptomatic. Ihe etiology of these rings is debated: they may form over time in response to GERD.10 Steakhouse syndrome, food impaction in the esophagus due to poorly chewed meat, is a frequent presentation for patients with this obstructive phenomenon. Ireatment of Schatzki's ring is dilatation.
Esophageal webs are thin structures of mucosa and submucosa found most often in the mid- or proximal esophagus. Ihey can be congenital or acquired. Esophageal webs are a component of Plummer-Vinson syndrome (along with iron-deficiency anemia), and can be seen in patients with pemphigoid and epidermolysis bullosa. Ireatment, again, is dilatation.
Diverticula may be found throughout the esophagus. Pharyngoesophageal, or Zenker's, diverticulum is a progressive outpouching of pharyngeal mucosa, just above the UES, caused by increased pressures during the hypopharyngeal phase of swallowing.7 Presentation is usually after age 50, as this is an acquired disease. Patients complain of typical transfer dysfunction; additionally, they may have halitosis and the feeling of a neck mass. Diverticula can also be seen in the body of the esophagus, usually in association with a motility disorder.
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