Esophageal cancer differential diagnosis: Difference between revisions

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|-
|-
! align="center" style="background:#DCDCDC;" + |[[Esophageal stricture]]  
! align="center" style="background:#DCDCDC;" + |[[Esophageal stricture]]  
| align="left" style="background:#F5F5F5;" + |Sudden onset and gradual progressive dysphasia to solids
| align="center" style="background:#F5F5F5;" + |Sudden onset and gradual progressive dysphasia to solids
| align="center" style="background:#F5F5F5;" + |+/-
| align="center" style="background:#F5F5F5;" + |±
| align="center" style="background:#F5F5F5;" + |+/-
| align="center" style="background:#F5F5F5;" + |±
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
* [[Odynophagia]]
* [[Odynophagia]]
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* [[Esophagogram|Barium esophagogram]]
* [[Esophagogram|Barium esophagogram]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Diffuse esophageal spasm]]
! align="center" style="background:#DCDCDC;" + |[[Diffuse esophageal spasm]]
|Sudden non-progressive dysphagia to solid and liquid
| align="center" style="background:#F5F5F5;" + |Sudden non-progressive dysphagia to solid and liquid
|<nowiki>+</nowiki>
| align="center" style="background:#F5F5F5;" + | +
|<nowiki>+</nowiki>
| align="center" style="background:#F5F5F5;" + | +
|
| align="left" style="background:#F5F5F5;" + |
* [[Chest pain]]
* [[Chest pain]]
|
| align="left" style="background:#F5F5F5;" + |
* Nonperistaltic and nonpropulsive contractions
* Nonperistaltic and nonpropulsive contractions
* Corkscrew or rosary bead esophagus
* Corkscrew or rosary bead esophagus
[[Image:DES radio.png|center|200px|thumb|Barium swallow appearance of DES<br>Source:By Nevit Dilmen [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]]
[[Image:DES radio.png|center|200px|thumb|Barium swallow appearance of DES<br>Source:By Nevit Dilmen [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]]
|
| align="left" style="background:#F5F5F5;" + |
* Inconclusive
* Inconclusive
<div style="width:350px">{{#ev:youtube|2ipA34iMA3c}}</div>
<div style="width:350px">{{#ev:youtube|2ipA34iMA3c}}</div>
|
| align="left" style="background:#F5F5F5;" + |
*[[Manometry]] shows high-amplitude [[esophageal]] contractions
*[[Manometry]] shows high-amplitude [[esophageal]] contractions
*[[CT scan]] may show [[hypertrophy]] of esophageal muscles
*[[CT scan]] may show [[hypertrophy]] of esophageal muscles
|
| align="left" style="background:#F5F5F5;" + |
* [[Manometry]]
* [[Manometry]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Achalasia]]
! align="center" style="background:#DCDCDC;" + |[[Achalasia]]
|Gradual non-progressive dysphagia to
| align="center" style="background:#F5F5F5;" + |Gradual non-progressive dysphagia to solid and liquid
solid and liquid
| align="center" style="background:#F5F5F5;" +
| +/-
| align="center" style="background:#F5F5F5;" + | -
| -
| align="left" style="background:#F5F5F5;" + |
|
* [[Dyspnea]]
* [[Regurgitation]] of undigested food
* [[Regurgitation]] of undigested food
* [[Chest pain]]
* [[Chest pain]]
|
* [[Cough]]
| align="left" style="background:#F5F5F5;" + |
* "Bird's beak" or "rat tail" appearance  
* "Bird's beak" or "rat tail" appearance  
* Dilated esophageal body
* Dilated esophageal body
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* Absence of an intragastric air bubble
* Absence of an intragastric air bubble
[[Image:Achalasia-2.jpg|center|200px|thumb|Case courtesy of Dr Mario Umana, Radiopaedia.org, rID: 38071]]
[[Image:Achalasia-2.jpg|center|200px|thumb|Case courtesy of Dr Mario Umana, Radiopaedia.org, rID: 38071]]
|
| align="left" style="background:#F5F5F5;" + |
* Dilated [[esophagus]]
* Dilated [[esophagus]]
* Residual food fragments  
* Residual food fragments  
* Normal [[mucosa]]  
* Normal [[mucosa]]  
<div style="width:350px">{{#ev:youtube|ydLcskQzEjM}}</div>
<div style="width:350px">{{#ev:youtube|ydLcskQzEjM}}</div>
|
| align="left" style="background:#F5F5F5;" + |
* Residual pressure of [[Lower esophageal sphincter|LES]] > 10 mmHg
* Residual pressure of [[Lower esophageal sphincter|LES]] > 10 mmHg
* Incomplete relaxation of the [[Lower esophageal sphincter|LES]]
* Incomplete relaxation of the [[Lower esophageal sphincter|LES]]
* Increased resting tone of [[Lower esophageal sphincter|LES]]
* Increased resting tone of [[Lower esophageal sphincter|LES]]
* Aperistalsis
* Aperistalsis
|
| align="left" style="background:#F5F5F5;" + |
* History of [[dysphagia]] with positive [[endoscopy]] and [[manometry]]
* History of [[dysphagia]] with positive [[endoscopy]] and [[manometry]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Systemic sclerosis]]
! align="center" style="background:#DCDCDC;" + |[[Systemic sclerosis]]
|Gradual progressive dysphasia to
| align="center" style="background:#F5F5F5;" + |Gradual progressive dysphasia to solid and liquid
solid and liquid
| align="center" style="background:#F5F5F5;" +
| +/-
| align="center" style="background:#F5F5F5;" + | +
| +
| align="left" style="background:#F5F5F5;" + |
|
* [[Muscle pain|Muscle]] and [[Arthralgia|joint pain]]
* [[Muscle pain|Muscle]] and [[Arthralgia|joint pain]]
* [[Raynaud's phenomenon]]
* [[Raynaud's phenomenon]]
* [[Skin changes]]  
* [[Skin changes]]  
|
| align="left" style="background:#F5F5F5;" + |
* Dysmotility
* Dysmotility
* Patulous [[esophagus]]
* Patulous [[esophagus]]
|
| align="left" style="background:#F5F5F5;" + |
* [[Mucosal]] damage
* [[Mucosal]] damage
* [[Peptic]] stricture (advanced cases)
* [[Peptic]] stricture (advanced cases)
|Positive serology for
| align="left" style="background:#F5F5F5;" + |Positive serology for
* [[Antinuclear antibodies]]
* [[Antinuclear antibodies]]
* [[Rheumatoid factor]]
* [[Rheumatoid factor]]
* [[Creatine kinase]]
* [[Creatine kinase]]
* [[ESR]]
* [[ESR]]
|
| align="left" style="background:#F5F5F5;" + |
* [[Skin biopsy]]
* [[Skin biopsy]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Zenker's diverticulum]]
! align="center" style="background:#DCDCDC;" + |[[Zenker's diverticulum]]
|Gradual dysphasia to
| align="center" style="background:#F5F5F5;" + |Gradual dysphasia to solid
solid
| align="center" style="background:#F5F5F5;" +
| +/-
| align="center" style="background:#F5F5F5;" + | -
| -
| align="left" style="background:#F5F5F5;" + |
|
* Food [[regurgitation]]
* Food [[regurgitation]]
* [[Halitosis]]
* [[Halitosis]]
* [[Coughing|Cough]]
* [[Coughing|Cough]]
* [[Hoarseness]]
* [[Hoarseness]]
|
| align="left" style="background:#F5F5F5;" + |
* Thin projections on [[esophageal]] wall over [[Killian's dehiscence|Killian's triangle]]
* Thin projections on [[esophageal]] wall over [[Killian's dehiscence|Killian's triangle]]
|
| align="left" style="background:#F5F5F5;" + |
* Outpouching of posterior [[pharyngeal]] wall
* Outpouching of posterior [[pharyngeal]] wall
* Exclude the presence of [[Squamous cell carcinoma|SCC]]
* Exclude the presence of [[Squamous cell carcinoma|SCC]]
<div style="width:350px">{{#ev:youtube|FdEruFsNdVA}}</div> 
<div style="width:350px">{{#ev:youtube|FdEruFsNdVA}}</div> 
|
| align="left" style="background:#F5F5F5;" + |
* [[CT]] & [[MRI]] shows out-pouching over the posterior esophagus in the Killian's triangle
* [[CT]] & [[MRI]] shows out-pouching over the posterior esophagus in the Killian's triangle
|
| align="left" style="background:#F5F5F5;" + |
* Barium [[Esophagogram|esophagography]]
* Barium [[Esophagogram|esophagography]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Stroke]]
! align="center" style="background:#DCDCDC;" + |[[Stroke]] ([[Cerebral hemorrhage]])
([[Cerebral hemorrhage]])
| align="center" style="background:#F5F5F5;" + |Sudden progressive dysphasia to solid and liquid
|Sudden progressive dysphasia to
| align="center" style="background:#F5F5F5;" + | +
solid and liquid
| align="center" style="background:#F5F5F5;" +
|<nowiki>+</nowiki>
| align="left" style="background:#F5F5F5;" + |
|<nowiki>+/-</nowiki>
|
* [[Dysarthria]]
* [[Dysarthria]]
* Limb [[weakness]]
* Limb [[weakness]]
* [[Fatigue]]
* [[Fatigue]]
|
| align="left" style="background:#F5F5F5;" + |
* Pooling of [[Contrast medium|contrast]] in the [[pharynx]]
* Pooling of [[Contrast medium|contrast]] in the [[pharynx]]
* [[Aspiration]] of [[barium]] [[Contrast medium|contrast]] into the [[airway]]
* [[Aspiration]] of [[barium]] [[Contrast medium|contrast]] into the [[airway]]
|
| align="left" style="background:#F5F5F5;" + |
* Reduced opening of [[upper esophageal sphincter]]
* Reduced opening of [[upper esophageal sphincter]]
* Reduced [[larynx]] elevation
* Reduced [[larynx]] elevation
|
| align="left" style="background:#F5F5F5;" + |
* [[CT]] without [[contrast]] shows acute [[hemorrhage]] as a hyperattenuating [[clot]]
* [[CT]] without [[contrast]] shows acute [[hemorrhage]] as a hyperattenuating [[clot]]
|
| align="left" style="background:#F5F5F5;" + |
* [[CT]] without [[Contrast medium|contrast]]
* [[CT]] without [[Contrast medium|contrast]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Motor disorders
! align="center" style="background:#DCDCDC;" + |Motor disorders ([[Myasthenia gravis]])
([[Myasthenia gravis]])
| align="center" style="background:#F5F5F5;" + |Gradual progressive dysphasia to solid and liquid
|Gradual progressive dysphasia to
| align="center" style="background:#F5F5F5;" +
solid and liquid
| align="center" style="background:#F5F5F5;" + |
|<nowiki>+/-</nowiki>
| align="left" style="background:#F5F5F5;" + |
|
|
* [[Ptosis]]
* [[Ptosis]]
* [[Diplopia]]
* [[Diplopia]]
* [[Fatigue]]
* [[Fatigue]]
|
| align="left" style="background:#F5F5F5;" + |
* Stasis in [[pharynx]] and pooling in pharyngeal recesses
* Stasis in [[pharynx]] and pooling in pharyngeal recesses
|
| align="left" style="background:#F5F5F5;" + |
* [[Velopharyngeal insufficiency]]
* [[Velopharyngeal insufficiency]]
* Delayed [[swallowing]] function
* Delayed [[swallowing]] function
|
| align="left" style="background:#F5F5F5;" + |
* CT may show anterior [[mediastinal]] mass ([[thymoma]])  
* CT may show anterior [[mediastinal]] mass ([[thymoma]])  
* Positive tensilon test  
* Positive tensilon test  
|
| align="left" style="background:#F5F5F5;" + |
* Anti–acetylcholine receptor antibody test
* Anti–acetylcholine receptor antibody test
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[GERD]]
! align="center" style="background:#DCDCDC;" + |[[GERD]]
|Sudden onset gradual progressive dysphasia to
| align="center" style="background:#F5F5F5;" + |Sudden onset gradual progressive dysphasia to solid
solid
| align="center" style="background:#F5F5F5;" +
| +/-
| align="center" style="background:#F5F5F5;" + | +
| +
| align="left" style="background:#F5F5F5;" + |
|
* [[Cough]]
* [[Cough]]
* [[Hoarseness]]
* [[Hoarseness]]
|
* Retrosternal burning [[chest pain]]
| align="left" style="background:#F5F5F5;" + |
* Free acid reflux
* Free acid reflux
* [[Esophagitis]] with scarring
* [[Esophagitis]] with scarring
* [[Strictures]]
* [[Strictures]]
* [[Barrett's oesophagus]]
* [[Barrett's oesophagus]]
|
| align="left" style="background:#F5F5F5;" + |
* [[Erythema]], erosions and [[ulceration]]
* [[Erythema]], erosions and [[ulceration]]
* [[Barrett's esophagus]]
* [[Barrett's esophagus]]
|
| align="left" style="background:#F5F5F5;" + |
* Esophageal [[manometry]] may show decreased tone of [[Lower esophageal sphincter|LES]]
* Esophageal [[manometry]] may show decreased tone of [[Lower esophageal sphincter|LES]]
|
| align="left" style="background:#F5F5F5;" + |
* 24 hour [[esophageal]] pH monitoring
* 24 hour [[esophageal]] pH monitoring
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Esophageal web]]
! align="center" style="background:#DCDCDC;" + |[[Esophageal web]]
|Gradual progressive dysphasia to
| align="center" style="background:#F5F5F5;" + |Gradual progressive dysphasia to solid and/or liquid
solid and/or liquid
| align="center" style="background:#F5F5F5;" + | -
| -
| align="center" style="background:#F5F5F5;" +
| +/-
| align="left" style="background:#F5F5F5;" + |
|
* Findings of the underlying cause such as [[iron deficiency anemia]] or [[bullous pemphigoid]]
* Findings of the underlying cause such as [[iron deficiency anemia]] or [[bullous pemphigoid]]
|
| align="left" style="background:#F5F5F5;" + |
* Symmetrical narrowing of the [[esophagus]]
* Symmetrical narrowing of the [[esophagus]]
|
| align="left" style="background:#F5F5F5;" + |
* Smooth membrane not encircling the whole [[Lumen (anatomy)|lumen]]
* Smooth membrane not encircling the whole [[Lumen (anatomy)|lumen]]
|
| align="left" style="background:#F5F5F5;" + |
* Videofluoroscopy shows [[mucosal]] and [[submucosal]] foldings
* Videofluoroscopy shows [[mucosal]] and [[submucosal]] foldings
|
| align="left" style="background:#F5F5F5;" + |
* Barium [[esophagogram]]
* Barium [[esophagogram]]
|}
{| class="wikitable"
!
!Manifestations
!Diagnostic tools
|-
|Achalasia
|
* Dyspnea<ref>{{cite book | last = Ferri | first = Fred | title = Ferri's clinical advisor 2015 : 5 books in 1 | publisher = Elsevier/Mosby | location = Philadelphia, PA | year = 2015 | isbn = 978-0323083751 }}</ref>
*[[Dysphagia]] for solids and liquids is the most common feature, being seen in 91 % and 85% of patients respectively<ref name="pmid23871090">{{cite journal| author=Boeckxstaens GE, Zaninotto G, Richter JE| title=Achalasia. | journal=Lancet | year= 2013 | volume=  | issue=  | pages=  | pmid=23871090 | doi=10.1016/S0140-6736(13)60651-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23871090  }}</ref>
*[[Regurgitation]] of undigested food occurs in 76-91% of patients<ref name="pmid23871090">{{cite journal| author=Boeckxstaens GE, Zaninotto G, Richter JE| title=Achalasia. | journal=Lancet | year= 2013 | volume=  | issue=  | pages=  | pmid=23871090 | doi=10.1016/S0140-6736(13)60651-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23871090  }} </ref>
*[[Cough]] mainly when lying down in 30%<ref name="pmid23871090">{{cite journal| author=Boeckxstaens GE, Zaninotto G, Richter JE| title=Achalasia. | journal=Lancet | year= 2013 | volume=  | issue=  | pages=  | pmid=23871090 | doi=10.1016/S0140-6736(13)60651-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23871090  }} </ref>
|
* Esophagogastroduodenoscopy findings include a dilated esophagus with residual food fragments, normal mucosa and occasionally [[candidiasis]] (due to the prolonged stasis).
* Barium swallow shows the characteristic bird's beak appearance.
[[Image:Acha.jpg|center|300px|thumb|Barium swallow showing bird's beak appearance - By Farnoosh Farrokhi, Michael F. Vaezi. - Idiopathic (primary) achalasia. Orphanet Journal of Rare Diseases 2007, 2:38(http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2040141), CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=2950922]]
|-
|[[GERD]]
|
* Retrosternal burning chest pain.
* Cough and hoarseness of voice.
* May present with complications such as strictures and dysphagia.<ref name="pmid25133039">{{cite journal |vauthors=Badillo R, Francis D |title=Diagnosis and treatment of gastroesophageal reflux disease |journal=World J Gastrointest Pharmacol Ther |volume=5 |issue=3 |pages=105–12 |year=2014 |pmid=25133039 |pmc=4133436 |doi=10.4292/wjgpt.v5.i3.105 |url=}}</ref>
|
* Upper GI endoscopy shows the complications such as esophagitis and barret esophagus.
* Esophageal manometry may show decreased tone of the lower esophageal sphincter.
* 24-hour esophageal pH monitoring may be done to confirm the diagnosis.
[[Image:Barretts esophagus.jpg|center|300px|thumb|Barret's esophagus - By Samir धर्म - taken from patient with permission to place in public domain, Copyrighted free use, https://commons.wikimedia.org/w/index.php?curid=1595945]]
|-
|[[Esophageal spasm|Corckscrew esophagus]]
|
*Retrosternal chest pain that presents with or without food intake.<ref name="pmid28943381">{{cite journal |vauthors=Matsuura H |title=Diffuse Esophageal Spasm: Corkscrew Esophagus |journal=Am. J. Med. |volume= |issue= |pages= |year=2017 |pmid=28943381 |doi=10.1016/j.amjmed.2017.08.041 |url=}}</ref>
*The condition is not progressive and not causing complications.<ref name="pmid1736462">{{cite journal |vauthors=Lassen JF, Jensen TM |title=[Corkscrew esophagus] |language=Danish |journal=Ugeskr. Laeg. |volume=154 |issue=5 |pages=277–80 |year=1992 |pmid=1736462 |doi= |url=}}</ref>
|
* Barium swallow shows the characteristic corckscrew appearance of the esophagus.
[[Image:Nutcracker-esophagus-004.jpg|center|300px|thumb|Corckscrew esophagus - Case courtesy of Radswiki, Radiopaedia.org, rID: 11680]]
|-
|[[Esophageal stricture]]
|
*Patient may present with the symptoms of the underlying GERD.
*Dysphagia and odynophagia.<ref name="pmid17227515">{{cite journal |vauthors=Ruigómez A, García Rodríguez LA, Wallander MA, Johansson S, Eklund S |title=Esophageal stricture: incidence, treatment patterns, and recurrence rate |journal=Am. J. Gastroenterol. |volume=101 |issue=12 |pages=2685–92 |year=2006 |pmid=17227515 |doi=10.1111/j.1572-0241.2006.00828.x |url=}}</ref>
|
* Barium esophagography provides information about the site and the diameter of the stricture before the endoscopic intervention.<ref name="pmid25013392">{{cite journal |vauthors=Shami VM |title=Endoscopic management of esophageal strictures |journal=Gastroenterol Hepatol (N Y) |volume=10 |issue=6 |pages=389–91 |year=2014 |pmid=25013392 |pmc=4080876 |doi= |url=}}</ref>
[[Image:Peptic stricture.png|center|300px|thumb|Peptic stricture - By Samir धर्म - From en.wikipedia.org, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1931423]]
|-
|[[Plummer-Vinson syndrome]]
|Common symptoms of  Plummer-Vinson syndrome include:<ref name="pmid11753173">{{cite journal |vauthors=López Rodríguez MJ, Robledo Andrés P, Amarilla Jiménez A, Roncero Maíllo M, López Lafuente A, Arroyo Carrera I |title=Sideropenic dysphagia in an adolescent |journal=J. Pediatr. Gastroenterol. Nutr. |volume=34 |issue=1 |pages=87–90 |year=2002 |pmid=11753173 |doi= |url=}}</ref><ref name="pmid4449772">{{cite journal |vauthors=Chisholm M |title=The association between webs, iron and post-cricoid carcinoma |journal=Postgrad Med J |volume=50 |issue=582 |pages=215–9 |year=1974 |pmid=4449772 |pmc=2495558 |doi= |url=}}</ref><ref name="pmid1192404">{{cite journal |vauthors=Larsson LG, Sandström A, Westling P |title=Relationship of Plummer-Vinson disease to cancer of the upper alimentary tract in Sweden |journal=Cancer Res. |volume=35 |issue=11 Pt. 2 |pages=3308–16 |year=1975 |pmid=1192404 |doi= |url=}}</ref>
*Difficulty swallowing (more for solids)
*[[Weakness]]
*[[Pain]]
*Burning sensation in mouth
*Dry tongue
*Painful cracks in the angles of a dry mouth
*Pale color of the skin
===Less common symptoms===
*Cold intolerance
*Reduced resistance to infection
*Altered behavior
*Craving for for unusual items (such as ice or cold vegetables)
|Lab tests are consistent with the diagnosis of iron deficiency anemia.
Findings on an [[x-ray]] ([[barium]] [[esophagogram]]) suggestive of [[esophageal web]]/[[strictures]] associated with Plummer-Vinson syndrome appear as either:
* Thin projections on the anterior [[esophageal]] wall.
* Multiple upper ([[cervical]]) [[Esophageal stricture|esophageal constrictions]] consistent with [[esophageal webs]].
[[Image:Plummer-vinson-syndrome.jpg|center|200px|thumb|Plummer-Vinson syndrome (Source: Case courtesy of Dr Hani Salam, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/14029">rID: 14029</a>)]]
|}
|}


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{{reflist|2}}
{{reflist|2}}


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Latest revision as of 21:40, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Parminder Dhingra, M.D. [2]Hadeel Maksoud M.D.[3]

Overview

Esophageal cancer must be differentiated from gastroesophageal reflux disease (GERD), Barrett's esophagus, esophageal achalasia, gastritis, gastric ulcer, and stomach cancer.

Differentiating Esophageal cancer from other Diseases

Approach to dysphasia

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dysphagia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Oropharyngeal dysphagia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Esophageal dysphagia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Solids only
 
 
 
 
 
 
 
 
 
 
 
 
Solids and Liquids
 
 
 
 
 
 
 
 
 
 
Solids only
 
 
 
 
 
 
 
 
 
Solids and Liquids
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Zenker's diverticulum
❑Neoplasm
❑Webs
 
 
 
 
 
 
 
 
 
Neurogenic
 
 
 
Myogenic
 
 
 
 
 
 
 
Pain
 
 
 
 
 
 
 
 
 
❑Achalasia
❑Scleroderma
❑DES
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Myasthenia gravis
❑Connective tissue disorder
❑Myotonic dystrophy
 
 
 
 
No
 
 
 
 
Yes
 
 
 
 
 
❑Heart burn
 
 
 
 
 
 
 
Barium swallow
 
 
 
 
 
 
 
 
 
Mental status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Pill esophagitis
❑Caustic injury
❑Chemotherapy
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Impaired
 
 
 
Normal
 
 
 
 
Non progressive
 
 
 
Progressive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sac
 
 
Webs
 
 
Mass
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Scleroderma
 
 
 
❑Achalasia
❑DES
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Stroke
 
 
 
❑ALS
❑Parkinsonism
 
 
 
 
❑Rings
❑Webs
 
 
 
❑Strictures
❑Cancer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Zenker's diverticulum
 
 
❑Plummer-Vinson syndrome
 
 
❑Carcinoma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest pain and manometry
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Barium swallow
 
 
 
Weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Increase LES pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Rings
 
 
 
❑Webs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rapid
 
 
 
Slow
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Achalasia
 
 
 
❑DES
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Esophageal cancer
 
 
 
❑Strictures/GERD
 
 
 
 
 
 

Differentiating Esophageal cancer from other Diseases

Disease Signs and Symptoms Barium esophagogram Endoscopy Other imaging and laboratory findings Gold Standard
Dysphagia Weight loss Heartburn Other findings
Esophageal carcinoma Gradual progressive dysphasia to solid and liquid + ±
Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 4232f
{{#ev:youtube|5ucSlgqGAno}}
Plummer-Vinson syndrome Gradual non-progressive dysphagia to solids ± -
  • Glossitis
  • Koilonychia
  • Weakness
  • Pale color of the skin
  • Cold intolerance
  • Reduced resistance to infection
  • Altered behavior
  • Craving for for unusual items (such as ice or cold vegetables)
Barium esophagogram (Source: Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 14029)
{{#ev:youtube|HFfsTgsB6Pg}}
Triad of
Esophageal stricture Sudden onset and gradual progressive dysphasia to solids ± ±
  • Sacculations
  • Fixed transverse folds
  • Esophageal intramural pseudodiverticula   
Case courtesy of Dr Ahmed Abd Rabou, Radiopaedia.org, rID: 23008
{{#ev:youtube|vax5E-jMnQ}}
Diffuse esophageal spasm Sudden non-progressive dysphagia to solid and liquid + +
  • Nonperistaltic and nonpropulsive contractions
  • Corkscrew or rosary bead esophagus
Barium swallow appearance of DES
Source:By Nevit Dilmen [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)
  • Inconclusive
{{#ev:youtube|2ipA34iMA3c}}
Achalasia Gradual non-progressive dysphagia to solid and liquid ± -
  • "Bird's beak" or "rat tail" appearance
  • Dilated esophageal body
  • Air fluid level (absent peristalsis)
  • Absence of an intragastric air bubble
Case courtesy of Dr Mario Umana, Radiopaedia.org, rID: 38071
{{#ev:youtube|ydLcskQzEjM}}
  • Residual pressure of LES > 10 mmHg
  • Incomplete relaxation of the LES
  • Increased resting tone of LES
  • Aperistalsis
Systemic sclerosis Gradual progressive dysphasia to solid and liquid ± + Positive serology for
Zenker's diverticulum Gradual dysphasia to solid ± -
  • Outpouching of posterior pharyngeal wall
  • Exclude the presence of SCC
{{#ev:youtube|FdEruFsNdVA}}
 
  • CT & MRI shows out-pouching over the posterior esophagus in the Killian's triangle
Stroke (Cerebral hemorrhage) Sudden progressive dysphasia to solid and liquid + ±
Motor disorders (Myasthenia gravis) Gradual progressive dysphasia to solid and liquid ±
  • Stasis in pharynx and pooling in pharyngeal recesses
  • Anti–acetylcholine receptor antibody test
GERD Sudden onset gradual progressive dysphasia to solid ± +
Esophageal web Gradual progressive dysphasia to solid and/or liquid - ±
  • Smooth membrane not encircling the whole lumen

References

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