Physician Assistant Exam: Narrowing of the Esophagus
Some conditions cause a narrowing of the esophagus, making swallowing difficult. Here are five conditions that you may encounter on the Physician Assistant Exam (PANCE) and when treating patients in your practice.
Achalasia refers to a failure of the lower esophageal sphincter to relax and failure of the lower esophagus to have meaningful peristalsis. This can make swallowing and digesting food impossible. The diagnosis is suggested by a barium swallow, which reveals what looks like a bird’s beak at the distal end of the esophagus — know this for the test! The diagnosis of achalasia can be confirmed via esophageal manometry.
Treatment for this condition can be medical or surgical. The medical treatment involves using botulinum toxin injections to try to relax the sphincter. Surgical intervention includes a Heller myotomy, in which the muscles of the lower esophageal sphincter are cut. It’s considered very effective.
Esophageal rings and webs
Esophageal webs and rings are common anatomic abnormalities of the esophagus. They usually cause a narrowing of the esophageal lumen. Here are two conditions to know for the test:
Schatzki’s ring: Schatzki’s ring is an anatomic narrowing of esophageal mucosa toward the distal end of the esophagus. Presenting symptoms include difficulty swallowing. The diagnosis is made by a barium swallow or esophagogastroduodenoscopy (EGD). Management includes dilating the affected area.
Plummer-Vinson syndrome: This is a triad of dysphagia due to an esophageal web, glossitis (a swollen but very smooth tongue), and iron deficiency anemia. It’s very common in people of Scandinavian descent and in postmenopausal women. The treatment often includes iron replacement therapy and balloon dilatation of the esophagus via endoscopy.
Esophageal stricture is a condition caused by a narrowing of the esophagus. Causes include inflammation, motility disorders, and toxic ingestions. (Esophageal stricture is what happens when you drink lye, which is never a good idea.) If esophagitis is the cause of the stricture, then you can administer medications. Also, depending on the severity of the stricture, a balloon dilatation, which can be done via endoscopy, may be needed.
Esophageal spasm, sometimes called corkscrew esophagus, is a gastrointestinal cause of chest pain and pressure. It’s brought on by eating. The affected person may experience an intense chest pain that can mimic acute coronary syndrome. Esophageal spasm is often a diagnosis of exclusion. The treatment includes nitrates and/or calcium channel blockers.
Esophageal cancer can cause weight loss, dysphagia, and odynophagia. Be aware of two types of this cancer for the test. Adenocarcinoma is linked with Barrett’s esophagitis. The other histologic subtype is squamous cell carcinoma, which is related to tobacco and alcohol use.
Esophageal cancer can be diagnosed via an endoscopy as a mass obstructing the esophageal lumen. A barium swallow can demonstrate an apple-core deformity, showing a filling defect within the esophageal lumen.
The treatment for esophageal cancer is usually surgical, and it can involve an esophagectomy — a lengthy, complicated, high-mortality procedure. Not that there are any good cancers, but esophageal cancer is a particularly bad one.