CHU de Rennes, Hôpital Pontchaillou, Service d’explorations fonctionnelles digestives, 35033 Rennes cedex
CIC 1414, INPHY, Université de Rennes 1, Rennes, France
Dysphagia is a sensation of discomfort or obstacle to the descent of foods occurring during swallowing. There are two types of dysphagia: oropharyngeal dysphagia and esophageal dysphagia. Oropharyngeal dysphagia is suspected in case of pharyngeal pain, dysphonia, wrong way. These abnormalities justify ENT and neurological consultations. Esophageal dysphagia may be associated with regurgitation, chest pain, reflux symptoms and an alteration of the general status. The topography of the discomfort is not pathognomonic. In the case of esophageal dysphagia, esophagogastroduodenal endoscopy with biopsies should be performed as first-line investigation for an organic cause (benign or malignant endoluminal tumor, stenosis, diverticulum or esophageal ring). A thoracoabdominal CTscan and/or gastroesophageal echo-endoscopy is recommended, if the patient is more than 50 year old and has a recent history of rapid weight loss to eliminate a mediastinal mass or an infiltrating process of the esophageal gastric junction (EGJ). High resolution esophageal manometry is the gold standard in diagnosis of esophageal motility disorders. The Chicago classification allows its classification. Most important abnormalities are achalasia with impaired EGJ relaxation and absent peristalsis. Second abnormality is isolated impaired EGJ relaxation without major peristaltic abnormalities. Third abnormalities are major peristaltic abnormalities (esophageal spasms, jackhammer esophagus and absent peristalsis). Etiology of this motility disorders are EGJ obstruction, eosinophilic esophagitis, gastro-esophageal reflux disease, morphin intake, and idiopathic motility disorders. Treatments of achalasia were pneumatic dilation using balloon of progressive size and laparoscopic Heller myotomy. Both methods are highly efficacious, pneumatic dilation is less costly, but with symptom relapse in 25% of patients. Within the past years, peroral endoscopic myotomy (POEM) is progressively proposed as first intention treatment in experienced centers, with very high efficacy. Robust studies show better efficacy of POEM than others treatments in type III achalasia (with premature contractions). However, long term results are not known. Medical treatments (calcic antagonists, nitric donors) and botulinum toxin injection in esophagus are reserved to old patients with comorbidities. In non achalasic major motor disorders, it is necessary to discard an etiology. Medical treatments are proposed in first intention. Endoscopic treatments are reserved to severe symptoms and no effect of medical treatments.
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