Dysphagia

A 44-year old man is referred to a gastroenterologist by his PCP because of dysphagia for solid food and liquids (Box 1, Fig 3). The symptoms had begun about a year ago. They were intermittent and mild initially, but for the past few weeks bolus hold-up at the midthoracic level is perceived with almost all meals. He has no chest pain or odynophagia. There are no features of oropharyngeal dysphagia, and physical examination for nonesophageal causes of dysphagia is negative (Box 2). His weight has remained constant at 92 kg. The patient experiences heartburn once a week on average. A brief therapeutic trial with an H2 receptor antagonist, initiated by his PCP, eliminated his heartburn but had not resulted in improvement of the dysphagia. His medical history is otherwise unremarkable, and he does not take any drugs. There is no family history of GI disease.

Upper GI endoscopy is performed (Box 4) and excludes macroscopic esophagitis or any organic lesion causing esophageal obstruction (Box 5), and microscopic examination of biopsies taken from the distal as well as the proximal esophagus shows that there is no evidence of eosinophilic esophagitis or other histologic abnormality (Box 8). A barium swallow with marshmallow bolus challenge (Box 6) reveals no structural lesion and no impairment of transit through the esophagus (Box 7). Because of the presence of the mild reflux symptoms (Box 9), a trial of PPI, omeprazole 40mg twice daily, is initiated (Box 10). This does not result in improvement of the patient’s dysphagia (Box 11).

The gastroenterologist then arranges a manometric study of the esophagus (Box 13). This shows normal esophageal peristalsis, normal LES pressure and normal LES relaxation upon swallowing (Box 14). Concomitant impedance monitoring confirms complete bolus transit with nine of ten swallows, findings within the range of normal. The patient again denies any cervical symptoms (Box 16). A diagnosis of "functional dysphagia" is made (Box 20).