Differentials
Esophageal carcinoma
SIGNS / SYMPTOMS
Dysphagia is mainly for solids, although difficulty in swallowing liquids develops with advanced disease.
Weight loss may be severe.
INVESTIGATIONS
Barium swallow and endoscopy will show esophageal obstruction by the tumor.
Reflux esophagitis
SIGNS / SYMPTOMS
Can give rise to dysphagia through inflammatory swelling or a fibrotic peptic stricture, sometimes even in the absence of endoscopic abnormalities.
The patient will usually also report heartburn and acid regurgitation in addition to dysphagia.
INVESTIGATIONS
Endoscopy may show reflux esophagitis, with or without a peptic stricture. A hiatus hernia may be present below the stricture.
Barium swallow has low sensitivity for esophagitis but may show up strictures and hiatus hernias. Gastroesophageal reflux will likely be demonstrated.
Lower esophageal pH/impedance studies will demonstrate pathologic gastroesophageal reflux.
Connective tissue disorders (e.g., systemic sclerosis)
SIGNS / SYMPTOMS
Muscle and joint pain, Raynaud phenomenon, skin changes (e.g., rash, skin swelling, or thickening).
INVESTIGATIONS
Antinuclear antibodies, rheumatoid factor, creatine kinase, and erythrocyte sedimentation rate are useful initial screening tests for connective tissue pathology.
Esophageal spasm
SIGNS / SYMPTOMS
Chest pain is often more prominent than dysphagia, which tends to be intermittent.
INVESTIGATIONS
Manometry shows high-amplitude esophageal contractions rather than the aperistalsis usually seen in achalasia.
Eosinophilic esophagitis
SIGNS / SYMPTOMS
Presents with dysphagia or food bolus obstruction, often in young men with a history of atopy.
INVESTIGATIONS
Endoscopy may show a ringed esophagus with furrows and white spots. Esophageal biopsy shows eosinophilic infiltration (>15 eosinophils per high-power field).
Pseudoachalasia (or secondary achalasia)
SIGNS / SYMPTOMS
Underlying malignancy that mimics idiopathic achalasia.
Patients tend to be older, duration of symptoms shorter, and weight loss greater and more rapid.[38]
The dysphagia is clinically indistinguishable.
INVESTIGATIONS
Gastroscopic biopsy of gastroesophageal junction and cardia may demonstrate malignancy.
Findings at endoscopy, barium swallow, and manometry may be indistinguishable from achalasia.
Chagas disease
SIGNS / SYMPTOMS
Endemic to Latin America; multiple-organ involvement causing atonic colon, myocarditis, and Romana sign; swelling of the eyelids in acute disease.
INVESTIGATIONS
Microscopic examination of fresh blood with Giemsa staining of thick and thin blood films showing presence of Trypanosoma cruzi.
Polymerase chain reaction for precise identification of trypanosome subtype.
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