AGA Technical Review on Treatment of Patients With Dysphagia Caused by Benign Disorders of the Distal Esophagus
This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the committee on September 27, 1998.
ysphagia isthe perception that there is an impediment to the normal passage of swallowed material. Odynophagia is the sensation of pain on swallowing. Dysphagia can be caused by a number of disorders, benign and malignant, that involve either the oropharynx or the esophagus. The purpose of this report is to develop a rational approach to the treatment of adult patients who have dysphagia caused by benigndisorders of the distal esophagus. The report provides a critical review of pertinent literature on which to base this approach. Patient care strategies that emerge from the review are summarized in the accompanying American Gastroenterological Association (AGA) Medical Position Statement. For this report, the distal esophagus is defined, somewhat arbitrarily, as the segment of esophagus that extendsfrom the level of the aortic arch to the gastric cardia. The muscularis propria in this esophageal segment is composed predominantly of smooth muscle.1 Thus the distal esophagus is susceptible to three general categories of disease processes that can cause dysphagia (Table 1): (1) mucosal (intrinsic) diseases that narrow the lumen of the esophagus through inflammation, fibrosis, or neoplasia; (2)mediastinal (extrinsic) diseases that encase and obstruct the esophagus by direct invasion or through lymph node enlargement; and (3) diseases affecting the esophageal smooth muscle and its innervation that disrupt peristalsis, interfere with lower esophageal sphincter relaxation, or both. This review considers clinical reports on these disorders that have been published in peerreviewed journalssince 1966. The reports were identified primarily by a MEDLINE search using the following MeSH terms: deglutition disorders, esophageal dysphagia, esophageal stenosis, esophageal motility disorders, and esophageal achalasia. Clinical studies published only in abstract form are not included. However, even the peer-reviewed literature on the treatment of patients with dysphagia due to benignesophageal disorders consists predominantly of retrospective, uncontrolled studies of small, heterogeneous patient populations who were followed up only briefly. The conclusions that can be drawn from these reports often are limited, and the serious deficien-
cies in study design and execution often preclude meaningful meta-analyses. This report highlights the strengths and weaknesses of the mostrelevant studies.
History It has been estimated that the cause of dysphagia can be determined with an accuracy of approximately 80% on the basis of a careful history alone.2 Some key elements of the history for patients with dysphagia are highlighted below.
Is the dysphagia for solid foods, liquids, or both?
Mucosal and mediastinal diseases that involve the distal esophagus causedysphagia by narrowing the esophageal lumen. Such narrowings usually pose little barrier to the passage of liquids, and consequently these diseases characteristically cause dysphagia only for solid foods.3 In contrast, diseases that disrupt peristalsis by affecting the smooth muscle and its innervation may cause dysphagia for both solids and liquids. In achalasia, persistent contraction of thelower esophageal sphincter (LES) causes complete mechanical obstruction of the esophagus that persists until either the sphincter relaxes or the hydrostatic pressure of the retained material exceeds the pressure generated by the sphincter muscle. Even in the absence of peristalsis, gravity often can empty the esophagus of liquid material effectively if the LES is relaxed. Therefore, patients who...