Dysphagia is the symptom that anchors the esophagus chapter, and the
whole game is getting to the right test on the first move. Fix the
vignette to one quadrant of a two-by-two, anatomy against mechanism,
and the test selection falls out of the sort rather than being
memorized. This episode builds that grid, then stress-tests it against
the alarm-feature framework and the cases that break a careless read.
The case. A 55-year-old woman has twelve months of progressive dysphagia to
solids and liquids, regurgitation of undigested food, nocturnal cough,
and weight loss. EGD shows a dilated body with residue and a junction
that passes with gentle pressure, no mass, biopsies unremarkable. The
story is classic achalasia. Do you proceed to myotomy?
Topics covered
- Two axes: oropharyngeal versus esophageal, mechanical narrowing versus motility
- Localization: throat plus airway symptoms versus substernal sticking after the swallow
- Oropharyngeal causes are neuromuscular: stroke, Parkinson, ALS, myasthenia, radiation
- Modified barium swallow with a speech pathologist reads the swallow itself; EGD cannot
- Solids-only progressive: ring, web, peptic stricture, EoE, malignancy
- Solids-and-liquids from the start: achalasia, spasm, jackhammer, scleroderma
- EGD with two-level biopsies even on normal-looking mucosa, because EoE is histologic
- Barium esophagram and high-resolution manometry as the second-line motility tests
- Alarm features raise malignancy pretest probability; they do not decide whether to scope
- Zenker diverticulum: barium first so the scope does not perforate the pouch
Key decisions
- New dysphagia is itself an alarm symptom: a 35-year-old with solid-food dysphagia still gets EGD; the over-50 cutoff is a dyspepsia rule, not a dysphagia rule
- Throat plus cough, nasal regurgitation, or drooling routes to modified barium swallow, not EGD; EGD sees mucosa, not the swallowing maneuver
- Solids-only that progresses over months with weight loss in an older patient is esophageal cancer until proven otherwise
- A classic achalasia story still needs manometry before a myotomy: subtype changes the procedure, and pseudoachalasia from a cardia tumor mimics the picture
- Borderline manometry (IRP just over cutoff, no pressurization) is inconclusive: FLIP or timed barium before the operating room, not a myotomy
For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.
Questions or feedback: hello@boardpearls.com.
- (00:00) - Opening: the two axes of dysphagia
- (01:30) - Localization: where the patient points
- (03:30) - Oropharyngeal dysphagia and the modified barium swallow
- (06:00) - Esophageal dysphagia: reading the pattern
- (08:30) - EGD with biopsies as the workhorse first test
- (11:00) - The alarm-feature framework and the age-cutoff trap
- (13:30) - Zenker diverticulum: why barium leads
- (16:00) - The case that does not fit: manometry before myotomy
- (19:00) - The algorithm in a handful of moves
