Types of Oesophageal Dysphagia: Structural, Motility and Malignant Causes

Oesophageal dysphagia accounts for a substantial proportion of dysphagia referrals and encompasses a wide spectrum of pathological entities — from benign mechanical strictures to life-threatening malignancy, from rare motility disorders to common reflux complications. Accurate classification guides investigation, determines appropriate specialist, and shapes management.

This article follows ASHA Practice Portal guidance on adult dysphagia and NICE CG162.

Overview: The Three Categories

Oesophageal dysphagia is classically divided into:

1. Structural (mechanical) causes — physical narrowing or obstruction of the oesophageal lumen
2. Motility (functional) disorders — impaired peristaltic or sphincteric function without structural obstruction
3. Malignant causes — oesophageal or gastro-oesophageal junction cancer, which may have both structural and motility components

The dysphagia history provides powerful diagnostic clues before any investigation:

• Solids only, intermittent: suggests benign structural cause (ring, stricture)
• Solids initially, progressing to liquids over weeks–months: suggests malignancy or rapidly progressive stricture
• Both liquids and solids from onset: suggests motility disorder (achalasia, oesophageal spasm)
• Associated heartburn, long history: suggests peptic stricture or Barrett’s oesophagus
• Regurgitation of undigested food: suggests achalasia or Zenker’s diverticulum
• Chest pain during swallowing (odynophagia): suggests spasm, oesophagitis, or mediastinal mass

Structural Causes

Peptic Stricture

The most common benign oesophageal stricture. Chronic gastro-oesophageal reflux disease (GORD) causes progressive fibrous scarring at the distal oesophagus, narrowing the lumen. Presenting features:

• Long history of heartburn before dysphagia develops
• Initially to solid foods; liquids remain unaffected until significant narrowing
• Associated with Barrett’s oesophagus (pre-malignant metaplasia requiring surveillance)

Investigation: Upper GI endoscopy (OGD) confirms the stricture, allows biopsy to exclude malignancy, and permits therapeutic dilatation at the same sitting.

Management: Endoscopic balloon or bougie dilatation plus long-term proton pump inhibitor (PPI) therapy to prevent re-stricturing. Patients may require repeat dilatations.

Schatzki Ring

A thin mucosal ring at the squamocolumnar junction (gastro-oesophageal junction). Typically produces intermittent dysphagia to solid foods — the classic “steakhouse syndrome” where a patient is periodically unable to swallow a piece of meat. Between episodes, swallowing is entirely normal.

Investigation: Barium swallow often demonstrates the ring more clearly than OGD (rings can be missed at endoscopy if not specifically looked for). OGD allows dilatation at the time of diagnosis.

Management: Single endoscopic dilatation is highly effective. Long-term PPI may reduce recurrence.

Post-Radiotherapy Stricture

Radiation to the mediastinum (for lymphoma, lung or oesophageal cancer) can cause radiation-induced fibrosis and stricture formation weeks to years after treatment completion. These strictures tend to be dense, proximal, and resistant to repeated dilatation. This population also frequently has concurrent oropharyngeal dysphagia from radiation effects on swallowing musculature.

Oesophageal Web

Thin mucosal shelves in the proximal oesophagus, most commonly in the context of iron-deficiency anaemia (Plummer-Vinson / Patterson-Brown-Kelly syndrome). Usually found in middle-aged women with a history of iron deficiency. Investigation by barium swallow or OGD; treatment by endoscopic dilatation plus iron supplementation.

Zenker’s Diverticulum

A posterior pharyngeal pouch at the Killian’s dehiscence (a natural weakness between the oblique and horizontal fibres of the inferior pharyngeal constrictor). Technically a hypopharyngeal rather than oesophageal lesion, but typically managed by gastroenterology or upper GI surgery.

Classic features: regurgitation of undigested food hours after eating; gurgling sound on swallowing; halitosis; aspiration particularly at night. Diagnosis by barium swallow. Treatment: endoscopic stapling or surgical repair.

Motility Disorders

Achalasia

Achalasia is characterised by:

• Absence of oesophageal peristalsis — no bolus-driving contractions
• Failure of lower oesophageal sphincter (LOS) relaxation — the LOS fails to open adequately with swallowing

The underlying cause is degeneration of inhibitory neurones in the oesophageal myenteric plexus (Auerbach’s plexus). Idiopathic in most cases; may be secondary to Chagas disease (Trypanosoma cruzi) in South American patients.

Presenting features: dysphagia to both liquids and solids from onset (distinguishes from early malignancy); regurgitation of undigested, non-acidic food; chest pain; weight loss; nocturnal cough (aspiration of retained oesophageal contents).

Investigation: High-resolution oesophageal manometry is the gold standard — shows aperistalsis and inadequate LOS relaxation with elevated integrated relaxation pressure (IRP). Barium swallow shows classic “bird’s beak” tapering at the LOS. OGD excludes pseudoachalasia (malignancy at the cardia mimicking achalasia).

Management: Pneumatic dilatation, per-oral endoscopic myotomy (POEM), or laparoscopic Heller myotomy. Botulinum toxin LOS injection as a temporising measure or in unfit patients. There is no curative medical treatment.

Diffuse Oesophageal Spasm (DES)

Simultaneous, non-peristaltic, high-amplitude contractions affecting the oesophageal body. Classic presentation: intermittent chest pain (may mimic cardiac pain) plus dysphagia to both solids and liquids. Symptoms triggered by hot or cold food or stress.

Investigation: High-resolution manometry (premature contractions with DCI >450 mmHg·s·cm, normal IRP distinguishes from achalasia). Barium swallow may show “corkscrew” pattern.

Management: Calcium channel blockers, nitrates, PDE-5 inhibitors (symptomatic), or POEM in refractory cases.

Systemic Sclerosis (Scleroderma) Oesophagus

Fibrosis of oesophageal smooth muscle produces profound hypomotility and LOS incompetence. Virtually universal in systemic sclerosis. Severe GORD, peptic stricture, and aspiration are major complications. Management is symptomatic — PPI for reflux, soft/liquid diet, and head-of-bed elevation.

Malignant Causes

Oesophageal Cancer

Oesophageal cancer is the eighth most common cancer globally and carries a poor prognosis, largely because of late presentation. There are two major histological types:

• Squamous cell carcinoma (SCC): associated with smoking, alcohol, and hot drink consumption (particularly prevalent in East Asia); typically mid-oesophagus
• Adenocarcinoma: associated with GORD and Barrett’s oesophagus; lower oesophagus and cardia; rising incidence in Western countries

Both present with progressive dysphagia — initially to solids, then to liquids — and significant weight loss. This is a red flag dysphagia requiring urgent OGD.

In Hong Kong, oesophageal SCC is relatively more common than adenocarcinoma compared with Western countries, consistent with regional risk factor patterns. Any patient in Hong Kong presenting with rapidly progressive dysphagia and weight loss requires urgent upper GI endoscopy and oncology referral.

Management: Endoscopic stenting for palliation of advanced disease, allowing the patient to swallow adequate nutrition. Combined chemoradiotherapy and surgery for curative intent. SLT involvement for dysphagia management pre- and post-treatment.

Investigations: Summary

For Referral Guidance

See Oropharyngeal vs Oesophageal Dysphagia for help distinguishing the two types, and When to Refer to a Speech and Language Therapist for SLT referral criteria.

References

1. American Speech-Language-Hearing Association. Adult Dysphagia Practice Portal. https://www.asha.org/practice-portal/clinical-topics/adult-dysphagia/
2. National Institute for Health and Care Excellence. Stroke Rehabilitation in Adults (CG162). https://www.nice.org.uk/guidance/cg162
3. IDDSI. The IDDSI Framework. https://www.iddsi.org/framework
4. Logemann JA, et al. (2015). Disorders of deglutition. Handbook of Clinical Neurology, 129, 465–487. PMID: 26315994