Instructions
You are a medical student on placement in the gastroenterology clinic. Chloe Hobbs, 38, was referred by her GP with difficulty swallowing and is here for her test results. Her referral, an earlier gastroscopy report and the results are below.
Interpret the barium swallow and manometry results provided
Outline to the examiner:
- Your most likely diagnosis and differentials
- Next steps in management, including relevant investigations
- You do not need to take a history or examine the patient
GP referral letter
Twelve months of food and drinks sticking low behind the breastbone, both from the start, slowly worse. Brings up undigested food lying down at night; wakes coughing. Eats very slowly; stands, walks about or drinks water to get food down. Weight 64 kg a year ago, 58 kg last week. Little heartburn.
GP referral letter: background
Previously well. No asthma, eczema, hay fever or food allergies. No operations. Born and raised in Perth. Non-smoker; alcohol rarely. Pantoprazole 40 mg daily for 4 months, no better. No known drug allergies.
Gastroscopy report, 4 months ago (private)
Retained food and fluid in the oesophagus, which looked wide; mucosa only partly seen. Scope passed into the stomach with gentle pressure. Stomach and duodenum normal. Retroflexed view of the cardia not recorded. No mass seen. No biopsies taken.
Barium swallow, timed upright (3 weeks ago)
Chloe Hobbs. Oesophagus 5 cm wide along its length, widest in the lower third, with frothy retained food and a flat fluid level on top. Narrows smoothly and evenly from both sides over about 3 cm to a point at the junction; no shelf, notch or mass.
Barium swallow: emptying and movement
Column 11 cm at 1 minute, 10 cm at 2 minutes, 8 cm at 5 minutes (normal: empty by 1 minute). Thin intermittent stream into the stomach. No stripping wave on screening. No pouch, web or hiatus hernia.
High-resolution manometry (last week)
Chloe Hobbs. Median IRP 29 mmHg (under 15). 10 of 10 swallows failed, with no effective peristalsis. Pressurisation along the whole oesophagus in 7 of 10 swallows (under 20%). No premature contractions. Upper sphincter normal; no hiatus hernia.
Barium swallow, timed upright study (3 weeks ago)
| Item | Value | Reference range |
|---|---|---|
| Patient and study | Chloe Hobbs. Upright barium swallow: 200 mL of thin barium drunk over 1 minute; films at 1, 2 and 5 minutes, then screening of further swallows | - |
| Oesophageal width | Widened along its whole length; 5 cm across at its widest, in the lower third; not tortuous | <3 cm |
| Contents | Frothy, mottled material mixed with the barium; a flat fluid level at the top of the column | - |
| Lower end | Narrows smoothly and evenly from both sides over about 3 cm to a point at the junction with the stomach; the narrowed segment has a smooth outline with no shelf, notch, ulcer or mass | - |
| Flow into the stomach | Barium passes only as a thin, intermittent stream, mostly when the column is tall | - |
| Height of the barium column | 11 cm at 1 minute; 10 cm at 2 minutes; 8 cm at 5 minutes | Empties within 1 minute |
| Movement on screening | No stripping wave carries the barium down; barium moves up and down within the oesophagus | - |
| Stomach and duodenum | Normal outline where filled | - |
| Other | No pouch, web or hiatus hernia; no barium entered the airway | - |
High-resolution oesophageal manometry (last week)
| Item | Value | Reference range |
|---|---|---|
| Patient and study | Chloe Hobbs. High-resolution manometry; catheter passed into the stomach; 10 supine 5 mL water swallows | - |
| Lower oesophageal sphincter resting pressure | 48 mmHg | 13-43 mmHg |
| Median integrated relaxation pressure (IRP) | 29 mmHg | <15 mmHg |
| Failed swallows (no effective contraction) | 100% (10 of 10 swallows) | <50% |
| Swallows with pressurisation along the whole oesophagus | 70% (7 of 10 swallows) | <20% |
| Premature contractions (distal latency under 4.5 s) | None | - |
| Upper oesophageal sphincter | Normal resting pressure and relaxation | - |
| Hiatus | No hiatus hernia | - |