History
A 60-year-old lady presents with a longstanding history of dysphagia to both solids and liquids for several years. There is no odynophagia or weight loss. She did not seek any prior medical attention. Recently, she presents to the general medical ward with an episode of a severe chest infection.
•Temperature 38.5°C, pulse 120 bpm, BP 120/80mmHg, SaO2 98-100% on RA.
•Hydration is satisfactory.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•Auscultation of the chest reveals right lower zone crepitation.
•Abdominal examination reveals a soft, non-tender abdomen.
•No signs of oedema.
Investigations
•CBC — which reveals leukocytosis.
•Liver function tests are normal.
•Renal function tests are normal.
•Blood for culture to rule out septicaemia.
What is your differential diagnosis for her dysphagia?
•Achalasia.
•Chagas disease.
•Pseudoachalasia.
What other tests will you order?
•Sputum for culture and sensitivity.
•Chest X-ray for consolidative changes (Figure 27.1).
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Please describe what you see
A dilated tubular structure with an air-fluid level (arrows) is present in the mediastinum, which is suggestive of food residue in a dilated oesophagus.
How would you manage the acute medical condition?
•Keep the patient nil by mouth to prevent further aspiration.
•Start antibiotics with good anaerobic coverage.
After stabilisation, what would be the next investigation for her dysphagia?
Oesophagogastroduodenoscopy (OGD).
The OGD reveals a dilated oesophagus. No structural or mucosal abnormalities are identified.
What further investigation should be performed?
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