Symptoms such as difficulty swallowing or heartburn may indicate a disease of the esophagus. Possible esophageal diseases include functional disorders, inflammation, or tumors of the esophagus.
Esophageal diseases encompass various conditions affecting the esophagus, ranging from achalasia &to gastroesophageal reflux disease and esophagitis. Typical symptoms such as difficulty swallowing, belching, or chest pain often occur when swallowing. Early diagnosis is important for detecting inflammation of the esophagus or even esophageal cancer in a timely manner and to receive medical treatment.
The esophagus is an elastic muscular tube closed off at both its upper and lower ends by a sphincter muscle (esophageal sphincter). The esophagus is lined with squamous epithelial cells.
The upper sphincter prevents air from entering the esophagus during swallowing. The lower sphincter protects the esophagus from the backflow of stomach contents (reflux). The esophagus transports food from the throat to the stomach.
After swallowing, both sphincters open. The longitudinal and circular muscles (peristalsis) create wave-like cycles of contraction and relaxation.
All sections and functional units of the esophagus can be affected and cause symptoms.
Doctors classify esophageal disorders into:
You should have any symptoms evaluated promptly. Difficulty swallowing, in particular, can affect your nutritional status over the long term and thus reduce your quality of life. In addition, persistent swallowing difficulties may indicate cancer, which your doctor should diagnose as soon as possible. Severe swallowing difficulties also carry a risk of aspiration (inhaling food or liquid into the airway) or, particularly for older and frail individuals, aspiration pneumonia (pneumonia caused by aspiration).
Difficulty swallowing, regurgitation (backflow of food), and heartburn are characteristic symptoms of esophageal disorders. Pain behind the breastbone (retrosternal pain) is also often a sign of an esophageal disorder.
The cause of these symptoms is often inflammation.
If left untreated, heartburn can lead to esophageal inflammation (esophagitis) @ Henrie /AdobeStock
Causes of the inflammation may include:
If the nerve cells in the lower part of the esophagus are damaged, the lower esophageal sphincter can no longer relax (achalasia).
Spasmodic muscle contractions in the upper part of the esophagus (esophageal spasm, nutcracker esophagus, jackhammer esophagus) are also possible.
In both cases, food gets “stuck in the throat,” so to speak. This leads to severe coughing fits, regurgitation, and retrosternal pain.
Esophageal disease can have various causes.
These may include:
Unhealthy lifestyle and dietary habits increase the risk of esophageal disease.
Risk factors include:
Taking certain medications can also have a negative effect on the esophagus.
These medications include:
However, underlying conditions such as diabetes mellitus or Parkinson’s disease, which negatively affect nerve function, can also cause motility disorders.
In addition, allergic conditions can sometimes lead to chronic inflammation of the esophagus (eosinophilic esophagitis).
Finally, swallowing difficulties become more common with age. In these cases, severe dry mouth (xerostomia), dehydration (exsiccosis), or poor dental health often contribute to esophageal disease.
Your doctor will diagnose esophageal disease using various examination methods, depending on the initial suspicion.
Possible examination methods include:
Esophagoscopy (endoscopy)
During an esophagoscopy, the doctor examines your esophagus using a fiber-optic endoscope. A fiber-optic endoscope is a thin, flexible tube equipped with a light source and a camera.
Using a cytology brush, the doctor can take a biopsy.
This method is used in particular when there are changes in the esophageal mucosa.
These changes occur in cases of:
X-ray examination
: An X-ray examination is the standard method for diagnosing esophageal diseases. Your doctor will examine your esophagus using X-rays to assess peristalsis, elasticity, and the condition of the esophageal wall and mucosa.
Your doctor often performs this examination as a barium swallow. During this procedure, you drink a contrast agent in small sips while your doctor takes X-ray images of your esophagus.
The images provide information on:
For example, in achalasia, the lower esophagus takes on a champagne glass or S-shape (in later stages).
Achalasia of the esophagus @ bilderzwerg /AdobeStock
Endosonography
An ultrasound scan of the esophagus provides cross-sectional images. This allows the doctor to identify superficial and deeper lesions in the wall layers. These lesions include malignant tumors (carcinoma).
Motility tests (esophageal manometry)
During esophageal manometry, the doctor inserts a thin, flexible measuring catheter through the nose and down the esophagus to the stomach. The doctor then measures the pressure in the various sections of the esophagus as the catheter is slowly withdrawn.
Using the recorded data, the doctor assesses the function of the esophagus. For example, this allows the doctor to determine whether the lower esophageal sphincter exhibits elevated pressure (achalasia) or reduced pressure (sphincter insufficiency).
Intraesophageal pH monitoring
In this test, your doctor measures the pH level in the area of the lower esophageal sphincter over a 24-hour period. A low pH level indicates reflux disease, in which acidic stomach contents flow back into the esophagus.
If possible, your doctor will treat the underlying cause of the esophageal disorder to eliminate the trigger.
For example, in cases of achalasia, medications (nifedipine, isosorbide dinitrate) can reduce pressure in the lower esophagus during the early stages. However, they do not yield good long-term results.
Therefore, the doctor tends to treat the condition surgically.
Possible surgical procedures include:
Alternatively, the doctor may recommend an endoscopic injection of botulinum toxin, as the medication reduces sphincter tone (the tension of the ring-shaped muscle). However, the doctor must repeat the treatment every 6 to 12 months. It loses effectiveness with frequent use.
The paroxysmal pain associated with esophageal spasm can be relieved by antispasmodic medications such as Buscopan. As a preventive measure, your doctor may also prescribe medications (nitrates, calcium channel blockers) to be taken before meals.
In cases of reflux disease, your doctor will try to reduce the reflux—which is harmful to the esophagus—with proton pump inhibitors (PPIs). Antacids, which neutralize stomach acid, also help relieve typical accompanying symptoms (heartburn, belching).
If you do not respond to treatment or if complications arise, surgery may be recommended. In most cases, laparoscopic fundoplication according to the Nissen or Toupet method is performed.
In general, doctors rarely need to perform surgery. The prognosis for reflux disease is also favorable, even though long-term treatment is usually required.
If pathogens have caused inflammation of the esophagus (esophagitis), you will be prescribed medication to eliminate the bacteria.
Your doctor will treat eosinophilic esophagitis symptomatically with PPIs and steroids. You’ll also need to adjust your diet and avoid allergens.
Chemical burns require immediate endoscopic evaluation as well as conservative treatment with antibiotics and a nasogastric tube. Any resulting narrowing of the esophagus (strictures) will later be dilated endoscopically by your doctor.
In the case of cancer (esophageal carcinoma), treatment depends on the type and location of the tumor. The surgeon will remove early-stage and localized tumors surgically (endoscopic mucosal resection, submucosal dissection).
Your doctor will treat advanced and inoperable tumors with a combination of radiation and chemotherapy (radiochemotherapy). The 5-year survival rate for these treatment options ranges from 10 to 30 percent.
The treatment of esophageal diseases is provided by:
The course and prognosis always depend on the specific esophageal condition. It is important to have your symptoms evaluated by a doctor at an early stage. This is particularly true for difficulty swallowing and inflammation, as these conditions increase the risk of cancer.
Esophageal conditions often cause similar symptoms but can have very different causes. Your doctor can effectively treat most of these conditions with medication or surgery, ensuring they do not impair your quality of life.
Typical symptoms of esophageal disorders include difficulty swallowing or swallowing disorders (dysphagia), heartburn, chest pain when swallowing, or regurgitation of food or liquids. A feeling of pressure behind the breastbone, hoarseness, or weight loss can also be symptoms. These symptoms should be evaluated by a doctor as soon as possible.
Esophageal disease is usually diagnosed through a gastroscopy (endoscopy), during which the doctor examines the lining of the esophagus. In addition, pH monitoring may be used to measure the reflux of stomach acid, or manometry to assess the esophageal sphincter. Imaging techniques such as X-rays are also used.
Treatment depends on the cause of the condition. It usually involves medical management, and surgery may be performed if necessary. The goal is to relieve symptoms, reduce the reflux of stomach contents, protect the esophagus, and improve the patient’s quality of life.
Arastéh, K. et al. (2018): Duale Reihe: Innere Medizin. 4., überarbeitete Auflage, Stuttgart: Thieme.
Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e. V. (2021): S1-Leitlinie: Ösophagoskopie. (URL: https://www.awmf.org/uploads/tx_szleitlinien/017-060l_S1_Oesophagoskopie_2021-07.pdf).
Frieling, T. (2015): Erkrankungen der Speiseröhre: Viele Ursachen, ähnliche Symptome. (URL: https://www.pharmazeutische-zeitung.de/ausgabe-242015/viele-ursachen-aehnliche-symptome/).
Herold, G. (2020): Innere Medizin 2020. Berlin/Boston: De Gruyter.
Piper, W. (2013): Innere Medizin. 2., überarbeitete Auflage, Berlin/Heidelberg: Springer.
Stein, J./Wehrmann, T. (2006): Funktionsdiagnostik in der Gastroenterologie: Medizinische Standards. 2. Auflage, Berlin/Heidelberg: Springer.
