Synopsis
Use symptom chronology, endoscopy, biopsy, contrast imaging and high-resolution manometry to distinguish oesophageal narrowing from disordered propulsion without missing malignant pseudoachalasia.
- Mechanical narrowing usually affects solids first and becomes progressive; motility failure often affects liquids and solids from the outset.
- Intermittent solid impaction suggests a ring or eosinophilic remodelling even when routine swallowing between episodes is normal.
- Upper-GI endoscopy with adequate biopsies precedes manometry when obstruction or mucosal disease is plausible.
Key red flags
Rapid progression, weight loss, anaemia or new dysphagia in an older adult raises concern for malignancy or pseudoachalasia.
Severe chest or neck pain, subcutaneous emphysema, fever or sepsis after instrumentation suggests perforation.
Short history, marked weight loss, older age or resistance crossing the junction raises concern for infiltrating cancer despite an achalasia-like lumen.
Reasoning priorities
Exclude cancer, benign narrowing and mucosal disease before physiological testing.
Record lesion length, diameter, junction landmarks and scope passage. Histology is required because visual impression alone cannot separate benign inflammation from malignancy or eosinophilic disease.
Worked reasoning
A 74-year-old develops rapidly progressive liquid and solid dysphagia with 9 kg weight loss; the first endoscopy notes resistance at the gastro-oesophageal junction but no mucosal diagnosis.
- Treat the short progressive history, weight loss and difficult junction passage as evidence against assuming uncomplicated primary achalasia, even though liquids are affected.
- Expert repeat endoscopy identifies an irregular infiltrative cardia narrowing; targeted biopsies show poorly differentiated junctional adenocarcinoma, and contrast CT demonstrates junctional wall thickening with para-aortic nodal disease.
- Cancel the planned routine manometry and myotomy pathway. CT has established para-aortic nodal disease and obstruction is causing rapid nutritional decline, so after staging and goals-of-care discussion the oesophago-gastric cancer MDT recommends a self-expanding stent for prompt dysphagia relief, with dietetic support and oncology review.
- After stent placement the patient tolerates a soft diet and hydration; at the two-week nutrition review weight has stabilised, while pathology, oncology ownership and return advice for recurrent obstruction are documented.