Step 2 CK · Internal Medicine · Gastroenterology

Esophageal & Motility Disorders

Name: Esophageal & Motility Disorders
Creator: Veli Bakalov, MD

Localizing dysphagia, and the can't-miss ruptures behind vomiting

Gastroenterology·Upper GI Disorders·4 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Oropharyngeal dysphagia = trouble initiating a swallow with cough, choking, or nasal regurgitation (stroke, myasthenia, Zenker); esophageal dysphagia = food sticks in the chest seconds later.
Solids only = mechanical (progressive: cancer or peptic stricture; intermittent: ring or web); solids and liquids from the start = motility (achalasia, scleroderma, spasm).
Achalasia: loss of inhibitory Auerbach neurons, bird's-beak barium, manometry is the gold standard; endoscopy first to exclude pseudoachalasia from a GE junction tumor.
Achalasia treatment: pneumatic dilation, Heller myotomy, or POEM; botulinum toxin or nitrates/CCBs for poor surgical candidates; long-standing disease raises SCC risk.
Diffuse esophageal spasm = corkscrew esophagus with chest pain (CCBs, nitrates); scleroderma = patulous LES with severe GERD.
EoE: young atopic male with food impaction, rings and furrows, ≥15 eosinophils/hpf; treat with PPI, swallowed fluticasone or budesonide, elimination diet, or dupilumab.
SCC = upper/mid esophagus (smoking, alcohol, hot drinks, achalasia, caustics, Plummer-Vinson); adenocarcinoma = distal third from Barrett/GERD and obesity, most common in the US.
Zenker = pulsion diverticulum through Killian triangle (halitosis, regurgitation): barium swallow, no blind NG tube; Schatzki ring = steakhouse syndrome; Plummer-Vinson = web + iron deficiency + dysphagia.
Mallory-Weiss = mucosal GE-junction tear, self-limited hematemesis; Boerhaave = transmural rupture with pneumomediastinum and left effusion → water-soluble contrast or CT, emergency surgery.

Localizing dysphagia

Transfer vs transport. Oropharyngeal (transfer) dysphagia is trouble initiating a swallow, with coughing, choking, or nasal regurgitation; it is usually neuromuscular (stroke, myasthenia gravis, Parkinson disease, ALS) or due to a Zenker diverticulum. Esophageal (transport) dysphagia is food sticking seconds after swallowing, felt in the chest.

Where does it stick?At swallow initiation with cough or nasal regurgitation = oropharyngeal; seconds later in the chest = esophageal.
Solids only?Mechanical obstruction: progressive = cancer or peptic stricture; intermittent = ring or web.
Solids and liquids from the start?Motility disorder: achalasia, scleroderma, diffuse esophageal spasm.
First testOropharyngeal: videofluoroscopic swallow study. Esophageal: upper endoscopy (allows biopsy and dilation), with barium first if Zenker is suspected and manometry when the anatomy is normal.

A stepwise approach to dysphagia

Achalasia and other motility disorders

Achalasia. Loss of inhibitory (nitric oxide–releasing) neurons of the myenteric (Auerbach) plexus leaves the lower esophageal sphincter (LES) unable to relax, with high resting pressure and absent peristalsis. Most cases are idiopathic; Chagas disease (Trypanosoma cruzi) causes a secondary form. Patients have dysphagia to solids and liquids, regurgitation of undigested food, weight loss, and chest pain. Barium shows a dilated esophagus tapering to a bird's beak; manometry (incomplete LES relaxation, aperistalsis, high LES pressure) is the gold standard.

Always perform endoscopy in suspected achalasia to exclude pseudoachalasia from a tumor at the gastroesophageal junction.

Treating achalasia. Options are pneumatic balloon dilation (small perforation risk), laparoscopic Heller myotomy (usually with a partial fundoplication to limit reflux), or peroral endoscopic myotomy (POEM). Poor surgical candidates get endoscopic botulinum toxin injection, whose effect is temporary, or nitrates or calcium channel blockers. Long-standing achalasia raises the risk of esophageal squamous cell carcinoma.

Three motility disorders compared

Feature	Achalasia	Diffuse esophageal spasm	Scleroderma
Defect	Loss of inhibitory myenteric neurons	Uncoordinated contractions; premature contractions on manometry	Atrophy and fibrosis of distal esophageal smooth muscle
LES	Fails to relax; high pressure	Relaxes normally	Weak and patulous
Barium	Bird's beak, dilated esophagus	Corkscrew esophagus	Aperistaltic distal esophagus with free reflux
Clinical	Dysphagia, regurgitation, weight loss	Intermittent chest pain and dysphagia, often mimicking angina	Severe GERD, strictures, dysphagia
Treatment	Dilation, Heller myotomy, POEM	Calcium channel blockers or nitrates	High-dose PPI

Scleroderma is the mirror image of achalasia: a wide-open LES instead of one that will not relax.

Structural and inflammatory causes

Eosinophilic esophagitis (EoE). Classically a young atopic man (asthma, eczema, food allergy) with dysphagia and recurrent food impaction. Endoscopy shows stacked concentric rings (trachealization), linear furrows, and white exudates; biopsy shows at least 15 eosinophils per high-power field. Treat with a PPI, swallowed topical steroids (fluticasone or budesonide), dietary elimination, or dupilumab. An impacted bolus needs urgent endoscopy.

Schatzki ring. A distal mucosal (B) ring at the squamocolumnar junction, associated with a hiatal hernia. It causes intermittent solid-food dysphagia, the classic steakhouse syndrome of meat impaction, and is treated by dilation.

Plummer-Vinson syndrome. The triad of dysphagia, iron-deficiency anemia, and upper esophageal webs, often with glossitis and koilonychia, typically in middle-aged women. It raises the risk of esophageal squamous cell carcinoma; treat the iron deficiency and dilate the web.

Zenker diverticulum. A false (pulsion) diverticulum herniating through Killian triangle just above the cricopharyngeus (upper esophageal sphincter). Elderly patients have oropharyngeal dysphagia, halitosis, regurgitation of undigested food eaten hours earlier, gurgling, and aspiration. Diagnose with a barium swallow; treat with cricopharyngeal myotomy.

Avoid blind nasogastric tube or endoscope passage when Zenker is suspected; it can perforate the pouch.

Esophageal cancer

Two cancers, two locations. Both cause progressive solid-food dysphagia with weight loss. Diagnose with upper endoscopy and biopsy, then stage with CT, PET, and endoscopic ultrasound for depth and nodes.

Squamous cell carcinoma vs adenocarcinoma

Feature	Squamous cell carcinoma	Adenocarcinoma
Location	Upper and middle esophagus	Distal third, near the GE junction
Risk factors	Smoking, alcohol, very hot beverages, achalasia, caustic injury, Plummer-Vinson	Chronic GERD with Barrett esophagus, obesity
Epidemiology	Most common worldwide	Most common in the US

Barrett esophagus. Chronic reflux replaces distal squamous epithelium with intestinal-type columnar epithelium containing goblet cells. It is the precursor of adenocarcinoma, so it is followed with surveillance endoscopy, and dysplasia is treated with endoscopic eradication such as radiofrequency ablation.

Vomiting-related emergencies

Mallory-Weiss tear vs Boerhaave syndrome

Feature	Mallory-Weiss tear	Boerhaave syndrome
Depth	Mucosal laceration at the GE junction	Transmural rupture, usually of the left distal esophagus
Setting	Retching or vomiting (alcohol use, bulimia)	Forceful vomiting
Findings	Hematemesis, usually self-limited	Chest pain, subcutaneous emphysema, Hamman crunch, pneumomediastinum, left pleural effusion with high amylase
Diagnosis	Endoscopy	CT or water-soluble (Gastrografin) esophagram
Treatment	Supportive; endoscopic therapy if bleeding persists	Surgical emergency: NPO, broad-spectrum antibiotics, repair

Why the urgency. Leaked gastric contents cause mediastinitis and sepsis, and mortality climbs steeply when repair is delayed beyond the first day. Iatrogenic injury during endoscopy is the most common cause of esophageal perforation overall.

Use water-soluble contrast, not barium, whenever perforation is suspected: extravasated barium causes mediastinitis.