Esophageal Disorders



  • Narrowing of esophagus from GERD (MC), esophagitis, radiation, caustic ingestion

  • SSX: Gradually progressive (worsening) dysphagia (solids)

  • DX: Barium esophagram shows narrowing at GE junction (MC)

    • Get endoscopy and biopsy to r/o esophagitis or malignancy


  • Eccentric (not concentric like a ring) membrane protruding into lumen, usually in cervical esophagus

  • Associated with Plummer Vinson syndrome

    • Websdysphagia (solids), Fe deficiency anemia ➔ splenomegaly, angular cheilitis, koilonychia (spoon nails)

  • Also associated with Zenker's Diverticulum, Bullous pemphigoid, and pemphigus vulgaris

  • DX: Barium esophagram shows asymmetric protrusion

    • No need for endoscopy and there is risk of rupture when passing endoscope over webs


  • Schatzki rings (not involving muscular layer) are associated with hiatal hernia and eosinophilic esophagitis

  • SSX: Usually asx but can have intermittent dysphagia (solids) depending on how completely food is chewed

    • (when pt has the occasional steak... they notice the sx)

  • DX: Barium esophagram shows concentric ridge above the esophageal hiatus

    • Get endoscopy and biopsy to r/o esophagitis

TX for strictures/webs/rings

  • Chew food completely

  • Push (bougie) or balloon dilation (will likely need multiple dilations)

  • PPI's prevent recurrence (regardless of GERD)

  • Refractory rings can get laser division, electrocautery division, or obliteration with biopsy forceps during EGD

Zenker's diverticulum

  • Outpouching of mucosa and submucosa of esophagus through a weak spot

    • Killian's triangle: between thyropharyngeal and cricopharyngeal parts of the lower inferior constrictor muscle

    • Associated with SCC

  • SSX: Food diverted into pouch ➔ oropharyngeal dysphagia (difficulty initiating swallowing, coughing/choking, nasal regurgitation)

    • Halitosis, gurgling, mass in throat, regurgitation, odynophagia from infection/inflammation

    • Fuller pouch ➔ complications: aspiration PNA, fistula connecting esophagus and trachea, vocal cord paralysis

  • DX: Barium esophagram (lateral view) with dynamic continuous fluoroscopy shows collection of contrast at hypopharynx

    • Can get endoscopy and biopsy to r/o SCC

  • TX: Surgery (diverticulotomy) when large



  • SSX: Gradually progressive (worsening) dysphagia to solids then liquids

  • Primary (idiopathic): Inflammation/degeneration of inhibitory neurons in myenteric (Auerbach) plexus of esophageal wall

    • Abnormal/no peristalsis in distal esophagus and lower esophageal sphincter (LES) fails to relax with swallowing

  • Secondary: Malignancy, Chagas (Trypanosoma cruzi), amyloidosis, sarcoidosis

    • Difficulty belching, chest pain, regurgitation/heartburn

  • DX: Esophageal manometry (High-resolution esophageal manometry is gold standard):

      • High relaxation pressure, incomplete LES relaxation with swallowing, aperistalsis in distal esophagus

    • Barium esophagram shows dilated esophagus filled with contrast and region of persistent narrowing (bird's beak)

    • Endoscopy with biopsy to r/o pseudoachalasia due to a malignancy

  • TX: ↓ LES resting pressure mechanically via pneumatic dilation, surgical myotomy, or peroral endoscopic myotomy (POEM)

    • or pharmacologically via botulinum toxin, or PO nitrates

Hypertensive/spastic motility disorders

  • SSX: Intermittent, non-progressive (non-worsening) dysphagia to liquids and solids

    • Chest pain exacerbated by stress, hot and/or cold food/drinks, regurgitation/heartburn

Diffuse esophageal spasm (corkscrew) ➔ non-progressive waves (non-peristaltic)

    • DX: Esophageal manometry (gold)

      • Normal amplitude (normal pressure) but repetitive (not coordinated/premature) contractions

    • Barium esophagram shows rosary bead/corkscrew esophagus when in spasm

Hypercontractile (nutcracker) progressive waves but high contractility

    • Jackhammer is a subtype with highest amplitude

    • DX: Esophageal manometry (gold)

      • Hypertensive peristalsis: high amplitude (high pressure) with normal (coordinated) contractions

  • TX: Control GERD, CCB (diltiazem) or TCA (imipramine)

    • Nitro can relieve spasm... So chest pain relieved with NTG is not diagnostic for cardiac chest pain 🤯