Chapter 40. Esophageal Emergencies

Complaints of dysphagia, odynophagia, or ingested foreign body implicate the esophagus. Chest pain, upper gastrointestinal (GI) bleeding, malignancy, and mediastinitis may also be esophageal in nature. Many diseases of the esophagus can be evaluated over time in an outpatient setting, but several, such as esophageal foreign body and esophageal perforation, must be addressed emergently.

Dysphagia is difficulty with swallowing. Most patients with dysphagia have an identifiable, organic cause. The two broad pathophysiologic groups of dysphagia are transfer dysphagia (oropharyngeal) and transport dysphagia. (esophageal).

Clinical Features

A careful history is the key to the diagnosis of dysphagia. Determine whether solids, liquids, or both cause the symptoms and the time course and progression of symptoms. Dysphagia for solids that progresses to liquids suggests a mechanical or obstructive process. Dysphagia for both solids and liquids points to a motility disorder. A poorly chewed meat bolus may obstruct the esophagus and be the presenting sign for a variety of underlying esophageal pathologies. Esophageal filling proximal to the impacted bolus can cause inability to swallow secretions and can present an airway or aspiration risk. Physical examination of patients with dysphagia should focus on the head and neck and the neurologic examination although the examination is often normal.

Diagnosis and Differential

The diagnosis of the underlying pathology of dysphagia is most often made outside the emergency department (ED). ED evaluation may include anteroposterior and lateral neck and chest x-rays. Direct laryngoscopy may identify structural lesions. Structural or obstructive causes of dysphagia include neoplasms (squamous cell is most common), esophageal strictures and webs, Schatzki ring, and diverticula. Motor lesions causing dysphagia include neuromuscular disorders (cerebrovascular accident is most common), achalasia, and diffuse esophageal spasm.

Emergency Department Care and Disposition

1. Aspiration is a major concern with most causes of dysphagia.

2. Most causes of dysphagia can be further evaluated and managed in the outpatient setting. Barium swallow is usually the first test for patients with transport dysphagia. Oropharyngeal dysphagia is best worked up by video esophagography.

3. Many of the structural lesions ultimately will require dilatation as definitive therapy.

Differentiating esophageal pain from ischemic chest pain can be difficult or impossible in the ED. Patients with esophageal pain report symptoms that are also found in patients with coronary artery disease, and there is no historical feature that is sensitive or specific enough to differentiate the two. The best ED default assumption is that pain is cardiac in nature and not esophageal until proven otherwise.

Gastroesophageal Reflux Disease

Reflux of gastric contents into the esophagus causes a wide array of symptoms and long-term effects. It affects up to 20% of the adult population in the United States.

Clinical Features

Heartburn is the classic symptom of gastroesophageal reflux disease (GERD) although chest discomfort may be the only symptom. ...