Differentials
Peptic ulcer disease
SIGNS / SYMPTOMS
Presentation may be similar. Upper central abdominal pain usually intermittent with peptic ulcer disease. Nausea, anorexia, and vomiting are uncommon. Usually absence of alarm features (weight loss, bleeding, anaemia, vomiting, early satiety, or dysphagia, or dyspeptic symptoms develop after age 55 years).
INVESTIGATIONS
Endoscopy and biopsy show benign ulcer.
Multiple biopsies (at least 6-7) from the edge and base of the ulcer are recommended to maximise diagnostic yield. All peptic ulcers should have repeat endoscopy after treatment to document healing.
Benign oesophageal stricture
SIGNS / SYMPTOMS
Usually associated with a long history of heartburn and slowly progressive dysphagia.
INVESTIGATIONS
Oesophagogastroduodenoscopy shows stricture of benign aetiology.
Achalasia
SIGNS / SYMPTOMS
Long history of regurgitation with no history of heartburn. Drinking fluid may initially cause a sensation of retrosternal pressure, which is relieved by continued drinking. May be clinically indistinguishable from stomach cancer. Achalasia more likely if symptoms present for more than 6 months, age <60 years, and weight loss is gradual, mild, and relative to the duration of symptoms.[44]
INVESTIGATIONS
Upper gastrointestinal series shows a typical 'bird's beak' filling defect.
Caution is required to differentiate achalasia from pseudoachalasia (which is caused by a primary or secondary malignancy in the majority of patients). It is crucial therefore to follow up with an endoscopy for mucosal assessment and biopsy.
Oesophagogastroduodenoscopy has low sensitivity for the diagnosis of achalasia, and is often reported to be normal in early achalasia.
Esophageal manometry shows incomplete relaxation of the lower oesophageal sphincter.
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