Examkin

Question

Difficulty: HardGastroenterology and Hepatology

Evaluate the clinical presentations of esophageal dysphagia and match each patient to the most likely corresponding findings on diagnostic evaluation (esophageal manometry or upper endoscopy).

  • A 35-year-old man with progressive dysphagia to both solids and liquids, accompanied by nocturnal regurgitation of undigested food and a dilated esophagus on imaging.Aperistalsis in the distal two-thirds of the esophagus with incomplete lower esophageal sphincter (LES) relaxation
  • A 42-year-old woman with severe heartburn, progressive dysphagia to solids and liquids, and thickening of the skin on her fingers.Absent peristalsis in the lower two-thirds of the esophagus with severely decreased lower esophageal sphincter (LES) resting pressure
  • A 55-year-old man with unpredictable, episodic retrosternal chest pain and dysphagia to liquids and solids; cardiac workup is negative.Premature, simultaneous, multi-peaked non-peristaltic contractions with normal lower esophageal sphincter (LES) relaxation
  • A 48-year-old man with a 15-year history of poorly controlled gastroesophageal reflux, now presenting with progressive dysphagia to solids but not liquids.Normal esophageal peristalsis and lower esophageal sphincter (LES) function with a focal distal narrowing

Answer

Achalasia pairs with aperistalsis and incomplete LES relaxation; Systemic sclerosis pairs with absent peristalsis and decreased LES pressure; Diffuse esophageal spasm pairs with simultaneous contractions and normal LES relaxation; Peptic stricture pairs with normal motility and a focal distal narrowing.
Dysphagia evaluation requires differentiating between mechanical obstruction and motility disorders based on the pattern of symptom onset (solids vs. liquids). The 35-year-old man presents with achalasia, characterized by aperistalsis and incomplete LES relaxation. The 42-year-old woman has systemic sclerosis, causing smooth muscle atrophy leading to absent peristalsis and decreased LES pressure. The 55-year-old man has diffuse esophageal spasm, identified by simultaneous contractions with normal LES relaxation. The 48-year-old man has a peptic stricture, representing a mechanical obstruction with normal underlying esophageal manometry.

Step-by-Step Solution

1
Determine if the dysphagia is mechanical or a motility disorder.
Dysphagia to both solids and liquids indicates a motility disorder, while dysphagia to solids only indicates a mechanical obstruction.
Liquids can easily pass through mechanical obstructions like strictures unless they are severe, but motility disorders disrupt the neuromuscular transport of both solids and liquids.
2
Differentiate the motility disorders based on accompanying symptoms and manometric patterns.
Regurgitation and a dilated esophagus suggest achalasia (high or non-relaxing LES). Severe heartburn and skin thickening suggest systemic sclerosis (low LES). Episodic chest pain suggests diffuse esophageal spasm (simultaneous contractions, normal LES).
Each motility disorder has a distinct pathophysiology that correlates with specific manometry findings.
3
Evaluate the mechanical obstruction.
Long-standing reflux leads to a peptic stricture, causing focal narrowing with otherwise intact peristalsis.
Chronic acid exposure causes progressive fibrosis and scarring in the distal esophagus.

Key Concept

Clinical presentation and manometric findings of esophageal motility and mechanical disorders
Estimated Time:1m 30s
Rate this question

Topics

Gastroenterology and Hepatology

More questions from this topic