EN4.45 | Diseases of Oesophagus — Summary & Reflection

KEY TAKEAWAYS

Diseases of the oesophagus span a spectrum from common mucosal conditions (GORD, Barrett's oesophagus) to motility disorders (achalasia), structural anomalies (Zenker's diverticulum, oesophageal webs), traumatic emergencies (foreign body, perforation), and lethal malignancies (carcinoma). The cardinal presenting symptom is dysphagia: dysphagia to solids first suggests mechanical obstruction; dysphagia to solids and liquids from the outset suggests a motility disorder. Alarm features — progressive dysphagia, weight loss, odynophagia, haematemesis — mandate urgent upper GI endoscopy to exclude carcinoma.

The oesophagus has three natural narrowings (cricopharyngeus C6, aortic arch/left bronchus T4-5, diaphragmatic hiatus T10) where foreign bodies impact. Barium swallow is the first investigation for structural disease (characteristic appearances: bird-beak in achalasia, rat-tail in carcinoma, pharyngeal pouch filling); endoscopy with biopsy is definitive for mucosal disease and provides histological diagnosis.

GORD is managed stepwise: lifestyle → PPI → fundoplication. Barrett's oesophagus (intestinal metaplasia at the squamo-columnar junction, 0.5% annual cancer risk) requires endoscopic surveillance and ablation of dysplasia. Oesophageal carcinoma — SCC in the upper/middle third (tobacco/alcohol/achalasia) and adenocarcinoma in the lower third/GOJ (Barrett's/GORD) — is managed by surgery, chemoradiotherapy, or palliative stenting depending on stage. Button battery in the oesophagus is a 2–4-hour emergency. Oesophageal atresia type C (lower-segment TOF, ~85%) is a neonatal surgical emergency confirmed by the inability to pass an orogastric tube.

REFLECT

Consider the patient in the opening hook: a 55-year-old male with three months of progressive dysphagia (solids → semi-solids), 7 kg weight loss, tobacco and alcohol use, and a normal ENT examination. You have now completed this SDL. What is your clinical diagnosis? What investigation will you request first and why? What does the barium swallow appearance tell you, and when does the patient need endoscopy with biopsy?

Now reflect on the systems level: the Barrett's → adenocarcinoma surveillance programme exists because of a clear understanding of the premalignant sequence and a 0.5% per year risk estimate. If surveillance endoscopy every 3–5 years is the standard, what does that mean for the number of asymptomatic patients in your practice who require periodic endoscopy, and how should a primary care physician decide who needs referral for endoscopy in the first place? What are the resource implications in a district hospital setting in India, and how would you triage between urgent and elective endoscopy when capacity is limited?