Stuck in the Throat or Chest: Does Esophageal Pathology Matter?

Abstract

Introduction: Dysphagia, or difficulty swallowing, is a morbid manifestation of various esophageal disorders. Patients often localize symptoms to the cervical or substernal area where liquids or solids “get stuck”. The anatomical location of pathology may not correlate to the location of symptoms, leading to a delay in gastroenterology referral and diagnosis. To the best of our knowledge, no study has quantified the localization patterns of dysphagia across various esophageal pathologies. The aim of this study was to describe how common esophageal disorders such as achalasia, eosinophilic esophagitis (EoE), and gastroesophageal reflux disease (GERD) localize dysphagia to the cervical or substernal region. Methods: This study included patients presenting to a gastroenterology practice with symptoms of dysphagia who underwent endoscopy (EGD) or high-resolution manometry (HRM) to establish esophageal pathology. Patients were divided into 4 groups by final diagnosis: 1) Achalasia, 2) Esophageal dysmotility other than achalasia, 3) EoE, 4) Esophagitis/GERD/stricture. Esophageal dysmotility and achalasia were determined by HRM using the Chicago Classification in conjuncture with EGD, barium esophagram or a video swallow study. EoE was determined by eosinophilic count (≥15/hpf) in distal and middle/proximal samples. Esophagitis/GERD/stricture diagnosis was determined by visual EGD findings, pH bravo study and histology findings. Results: One hundred forty two patients were included in the analysis [median (IQR) age=56 (38-66); 59% female, 75% white]. Four diagnostic groups included: achalasia (N=52), EoE (N=16), esophagitis/GERD/stricture (N=47) and other dysmotility disorders (N=27). Overall, similar number of patients localized dysphagia to the cervical (N=67) and substernal regions (N=75). Achalasia patients localized dysphagia to the substernal region (75%) significantly (P=0.001) more than other groups of esophageal diseases with no difference among subtypes (P=0.27). Other esophageal disease more commonly localized dysphagia to the cervical region; EoE (56%), GERD/stricture (62%) and esophageal dysmotility other than achalasia (59%).Figure: Percentage of patients reporting dysphagia to the cervical or substernal region across esophageal pathology type. EoE, eosinophilic esophagitis; E+, esophagitis; GERD, gastroesophageal reflux disease; Stric, stricture.Conclusion: Localization of dysphagia to cervical region is different among esophageal diseases and is substantially more common than previously believed; especially in those with EoE and GERD occurring in nearly 60% of patients. However, patients with achalasia are more likely to localize dysphagia to the substernal region.