Assessment and management of dysphagia and achalasia

Dysphagia is a common symptom which can vary in severity and aetiology; at one end, it can be a benign inconvenience, on the other, there can be serious morbidity associated with malnutrition. It is crucial to identify those with mucosal and structural disease, including malignancy as a priority first. Reflux disease is commonly a culprit and treating empirically with acid reducing medicines should follow exclusion of organic disease. Other benign conditions (including eosinophilic oesophagitis) should be considered. The clinical assessment of dysphagia begins with a detailed history and a focus on symptom severity as well as the pre-test probability of a given condition. Tests are then directed at assessing function, and should employ both high-resolution manometry and barium studies. For motility disorders, begin by assessing the oesophago-gastric junction for obstruction (eg achalasia), followed by oesophageal body function. The latter is divided into major and minor motility disorders. Treatment is directed according to the dysmotility phenotype and is based upon background fitness, age and appetite to intervention. Invasive treatment for achalasia is aimed at disrupting the lower oesophageal sphincter muscle while that of oesophageal body disorders is directed at reducing hypercontraction, improving peristalsis or reducing symptoms.