I have a patient with typical reflux symptoms in whom adequate medical management has failed. So I'm planning fundoplication for her. Since she also complained of a "choking sensation" after intake of food, barium swallow was done that showed 'smooth mild narrowing of lower third esophagus'. Endoscopy showed no significant narrowing.
How should I proceed ?
if available esophageal manometry with ph. A swallow should show dysmotiltiy.
Hello,
here is an old paper's abstract discussing your problem. Perhaps you find something more from these authors:
Am Surg. 1985 Oct;51(10):563-6.
Achalasia mimicking peptic esophageal stricture.
Hocking MP, Ryckman FC, Woodward ER.
Abstract
Peptic stricture of the esophagus and achalasia both cause dysphagia. They are not always readily distinguished by history. The usual workup with upper gastrointestinal x ray and endoscopy may also fail to differentiate the two disorders. Two cases are presented wherein antireflux procedures were mistakenly performed when achalasia was present rather than peptic stricture. Dysphagia was unrelieved and extensive further procedures were required. In a third patient referred for a peptic stricture, manometry revealed the correct diagnosis and heller myotomy provided relief. It is recommended that manometry be performed as a part of the preoperative workup in patients in whom there is any element of dysphagia
Hello Ranga,It is a difficult problem in the early stage.As i can conciude from the Endoscopy report that there was no resistance at the GE junction reasonably excludes Achalasia.However oesophageal manometry and 24 hour ph studies are mandatory to distinguish.If available oesophageal impedence test also is adviceable.Till that time it is better wait.
ps.mail id please
Thanks, I am in Finland and the weather starts to turn cold again. Both sons are alive:)
Good to know ! Its always sunny in the Cayman Islands (I've moved there now) !
What was the appearance of the distal esophagus at endoscopy? Did it show any macroscopic sign of esophagitis? The "choking sense"? may be simply due to reflexe cervical achalasia secondary to gastroesophageal reflux.The easy passage of endoscope must R/O a fibrotic stricture.
If you have the possibility of performing esophageal manometry, I can recommend it. If not,you may perform an antireflux procedure.
Usually the endoscope passes through the obstructing area in achalasia but not in peptic stricture unless the achalasia is in very late stage. Of course this has to be confirmed by oesophageal manometry and pH metry