DIFFERENTIAL DIAGNOSIS OF

NEUROMUSCULAR DISEASE OF

THE ESOPHAGUS AND

ESOPHAGOCARDIA CANCER

BY DR. INNOCENT KINGSLEY ASOGWA

PFURMI ML – 608

DDx OF ACHALAZIA AND CARDIOSPASM

ConditionDifferentiating signs/symptoms

Differentiating tests

Oesophagealcarcinoma

•Dysphagia is mainly for solids, although difficulty in swallowing liquids develops with advanced disease.•Weight loss may be severe.

•Barium swallow and endoscopy will show oesophagealobstruction by the tumour.

ACHALASIA

ESOPHAGOCARDIA CANCER

ESOPHAGOCARDIA CANCER

Reflux oesophagitis •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.

•Endoscopy usually shows reflux oesophagitis, with or without a peptic stricture. A hiatus hernia may be present below the stricture.•Barium swallow has low sensitivity for oesophagitis but will show up strictures and hiatus hernias. Gastro-oesophageal reflux will likely be demonstrated.•Lower oesophagealpH studies will demonstrate pathological gastro-

BARRET ESOPHAGUS & ESOPHAGEAL REFLUX

Connective tissue disorders (e.g., systemic sclerosis)

•Muscle and joint pain, Raynaud's phenomenon, skin changes (e.g., rash, skin swelling or thickening).

•Antinuclear antibodies, rheumatoid factor, creatinekinase, and ESR are useful initial screening tests for connective tissue pathology.

Oesophagealspasm

•Chest pain is often more prominent than dysphagia, which tends to be intermittent.

•Manometryshows high-amplitude oesophagealcontractions rather than the aperistalsisusually seen in achalasia.

DIFFUSE ESOPHAGEAL SPASM

Eosinophilicoesophagitis

•Presents with dysphagia, or food bolus obstruction, often in young men with history of atopy.

•Endoscopy may show a ringed oesophagus with furrows and white spots. Esophageal biopsy shows eosinophilicinfiltration (>15 eosinophils per high-power field).

EOSINOPHILIC OESOPHAGITIS

Pseudoachalasia(or secondary achalasia)

•Underlying malignancy that mimics idiopathic achalasia.•Patients tend to be older, duration of symptoms shorter, and weight loss greater and more rapid.•Dysphagia is clinically indistinguishable.

•Gastroscopicbiopsy of gastro-oesophagealjunction and cardiamay demonstrate malignancy.•Findings at endoscopy, barium swallow, and manometry may be indistinguishable from achalasia.

PSEUDOACHALASIA (OR SECONDARY ACHALASIA)

Chagas' disease •Endemic to Latin America; multiple-organ involvement probably causing atonic colon, myocarditis, and Romana sign; swelling of the eyelids in acute disease.

•Microscopic examination of fresh blood with Giemsa staining of thick and thin blood films showing presence of Trypanosomacruzi.•PCR for precise identification of trypanosome subtype.