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A 52-year-old Malay man presented with a history of recurrent heartburn and intermittent dysphagia for 6 months. There was no history of vomiting or food regurgitation or any alarming symptom. He had previously sought treatment from several doctors with a presumptive diagnosis of gastro-oesophageal

A 73-year-old white man presents with left-sided ptosis and diplopia in the absence of ophthalmoplegia, with left hemibody paresthesia. He reports intermittent dysphagia and dizziness for 1 month and diarrhoea for 2 months. Serum and electrodiagnostic studies confirmed the diagnosis of myasthenia gravis. This case highlights the non-classic presentation of myasthenia gravis in the absence of ophthalmoplegia with a unique unexplained hemisensory deficit.

A 69-year-old woman presented to her local head and neck clinic with a 6-month history of right-sided sore throat and intermittent dysphagia, with a normal voice. On examination, a longitudinal, pulsatile lesion in the right posterolateral pharyngeal wall commenced at the junction of the oropharynx

A 34-year-old man presents to his family physician after completing a two-month trial of a proton pump inhibitor for heartburn. The heartburn, which had begun three months earlier, has not responded to the treatment. The patient describes experiencing intermittent difficulty swallowing solids (e.g

The voltage gated sodium channel SCN4A mutations account for non-dystrophic myotonia and include a heterogeneous group of conditions that include hyperkalemic periodic paralysis, paramyotonica congenita, potassium-aggravated myotonia, and hypokalemic periodic paralysis type 2. This case report proposes that a rare variant p.Pro1629Leu in SCN4A can cause a skeletal muscle deficit with intermittent dysphagia.

Post-traumatic epilepsy (PTE) can create diagnostic confusion when typical epileptic seizures are not manifest. Abdominal symptoms as a manifestation of PTE are rare in this setting. We present a 43-year-old female with paroxysmal chest and abdominal pain, nausea, salivation, and intermittent dysphagia. Esophageal testing demonstrated diffuse esophageal spasm, but smooth muscle relaxants provided no relief. Finally, after history revealed that a motor vehicle accident temporally preceded symptom onset, video electroencephalography confirmed PTE. Therapy with anti-epileptic drug completely resolved symptoms, and the esophageal motor pattern normalized. We speculate that abnormal epileptiform discharges from the seizure focus altered cerebral input to intrinsic esophageal innervation, resulting in inhibitory dysfunction and a picture resembling diffuse esophageal spasm. This is the first report of symptomatic esophageal spasm as a major ictal manifestation of PTE.

Die endoskopische Abklärung eines 18-jährigen Patienten mit Dysphagieattacken zeigte ausgedehnte weissliche Auflagerungen im Ösophagus. Primär als Soorösophagitis fehlinterpretiert fand sich histologisch das Bild einer schweren eosinophilen Ösophagitis. Unter Behandlung mit topischen Kortikosteroiden wurde der Patient beschwerdefrei. Die endoskopische Kontrolle zeigte auch histologisch eine Remission ohne Nachweis eosinophiler Granulozyten. Die eosinophile Ösophagitis ist eine seltene allergieartige Entzündung des Ösophagus, tritt vorwiegend bei jüngereren Männern auf und zeigt eine zunehmende Inzidenz. Unbehandelt können im Langzeitverlauf schwere Strikturen entstehen.

Abnormalities of the atlantoaxial spine are very rare variants. Bony outgrowths, osteophytes, clefts and aplasia may be misinterpreted as degenerative diseases. One patient presented with intermittent dysphagia and snoring and CT and MRI scans of the cervical spine showed an accessory bone located anterior to the atlas and axis. Atlantoaxial anomalies are often incidental findings without clinical symptoms. Such changes are rarely the cause of intermittent dysphagia and snoring.

To improve the management of dyspepsia by analyzing the clinical characteristics of dyspeptic symptoms in patients from Shanghai.782 patients with functional dyspepsia (FD) or organic dyspepsia (OD) completed a questionnaire about dyspepsia. The questionnaire asked participants to score 12 previously validated common upper abdominal symptoms. The clinical characteristics of dyspepsia including severe symptoms; and the relationship between symptoms and meals were then analyzed.Among the 782 dyspeptic patients, 543 cases (69.4%) were classed as FD and 239 (30.6%) OD. The proportion of males was significantly higher in the OD group. There was no difference in average dyspepsia scores between the 2 dyspeptic groups (21.5 vs 20.4, P0.05), but the scores of 'stomach' pain and 'stomach' pain before meals were higher in OD patients than in FD patients (2.65 +/- 1.11 vs 2.16 +/- 0.92, 2.26 +/- 1.26 vs 1.79 +/- 0.92, P0.05). In 45.2% of the OD patients and 47.7% of the FD patients, respectively, the severity of symptoms was not related to meals. In subgroups of ulcer-like, dysmotility-like and unspecified dyspepsia, the proportion of patients with symptoms not related to meals was 59.6%, 50.9% and 35.2%, respectively. 2.5% (6/239) of OD patients presented with progressive dysphagia, compared with 2.8% (15/543) of FD patients who presented with intermittent dysphagia. Approximately 8.8% (21/239) of OD patients reported dramatic weight loss accompanied with other severe symptoms, compared with 5.9% (32/543) of FD patients who had no other severe symptoms. A shift in symptom subtypes during the follow-up period was found in 13.8% of FD patients. The infection rate of Helicobacter pylori was higher in the OD group than in the FD group (53.1%vs 42.2%, P0.01), but no difference was found among the three subgroups of FD patients (P0.05). Halitosis was more often found in dyspeptic patients with H. pylori infection (44.9%vs 17.0% in OD, 47.3%vs 25.4% in FD, P0.01).When dyspepsia patients present with 'stomach' pain or 'stomach' pain before meals, a diagnosis of OD should be considered. Intermittent dysphagia, weight loss not accompanied with other severe symptoms, and halitosis (more often seen in patients with H. pylori infection) might be regarded as the relatively unique symptoms of dyspepsia in some FD patients. In FD, we found that the severity of dyspepsia symptoms was not related to meals in half of the patients, and symptom subtypes might shift over time, this adds difficulty to the management of FD.

Answers on p 360. A 40 year old engineer presented with a history of chronic left upper limb fatigue and pallor upon limb abduction and intermittent dysphagia. These symptoms caused significant interference with his daily life and had started after a fall onto his left shoulder during a rugby tackle nine years previously. Following the original injury he had attended an accident and emergency department where …

Polypoid tumours of the esophagus present diagnostic and therapeutic problems. Liposarcomas are infrequent among them. We report a recent case. A 73-year-old male patient was seen in May 1995 in the Ear, Nose and Throat (ENT) Department, Clinica Modelo de Moron, with intermittent dysphagia and dyspnoea due to recurrent vomiting. A laryngeal lineal tomography showed a subglottic obstruction due to extrinsic compression. The patient was referred to the Gastroenterology Department, where an upper gastrointestinal (upper GI) series demonstrated mega-esophagus with abundant retained food. Endoscopy showed a large intraluminal mass covered by normal mucosa which arose on the posterior wall. Videofluoroscopy and chest CT diagnosed a probable polypoid lipoma due to its densitometric characteristics. The tumour was resected by left cervicotomy and left esophagotomy. The patient's progress to date is favourable. Pathology studies showed a well-differentiated liposarcoma. According to the literature, the first case was reported in 1983, and ours is only the seventh case in the world to be documented.

Neurogenic tumors, especially paraganglioma of larynx, are rare. In this article, we present a 64-year-old woman who complained of intermittent dysphagia to solid foods. Further evaluation revealed a supraglottic paraganglioma and she was treated successfully by total excision of tumor.

(1997). Intermittent Dysphagia in a Casual Smoker. Hospital Practice: Vol. 32, No. 8, pp. 235-236.

[Figure][1] A 69-year-old man presented with a 2-year history of progressive thrombocytosis, referred to exclude essential thrombocythemia. He had been asymptomatic apart from intermittent dysphagia and a brief episode of amaurosis fugax a few weeks prior to his presentation. On examination

Five adolescents, 13-18 years of age, underwent esophageal manometric studies because of chronic symptoms suggestive of esophageal dysfunction. Four of five patients had episodic nonexertional midchest pain; two patients experienced intermittent dysphagia. The manometric findings for these adolescents were consistent with a primary motility disorder known as diffuse esophageal spasm, a condition not previously reported in this age group. This represents approximately 1% of all pediatric patients undergoing esophageal manometry at our institution for the past 5 years. They have been followed for at least 2 years and three have experienced gradual resolution of their symptoms with normalization of manometric findings. Our report emphasizes two main points: (a) Diffuse esophageal spasm may cause chest pain and dysphagia in adolescents; and (b) the clinical history and esophageal manometric findings establish the diagnosis of diffuse esophageal spasm.

Cardiomyotomy and fundoplication were performed in 7 children with achalasia of the oesophagus. They were followed up clinically, radiologically and manometrically from 7 to 18 years. Virtually all clinical symptoms and complaints disappeared immediately postoperatively and the patients remained free from symptoms well into adolescence except for very mild intermittent dysphagia in two of them. The residual mega-oesophagus and the disturbances of motility were least apparent in those operated on in early infancy. It may, therefore, be assumed that the motility pattern is more likely to return to normal in the oesophagus of the infant due to the relatively short period of dilatation. Fundoplication after Nissen did not alter the existing motility but was able to prevent gastro-oesophageal reflux and its possible grave consequences in all cases.

Manometric studies were carried out for thirteen cases of pharyngoesophageal reconstruction with free transplantation of jejunal segments in order to evaluate intermittent dysphagia during the early postoperative period. The following results were obtained.1. Dysphagia was observed when transplanted jejunum made spontaneous continuous contractions, and it disappeared after the contractions were subsided.2. Continuous waves were observed for 13.0% of the testing period with the duration of 3.6±3.5 minutes. The average value of the maximum pressure for the continuous waves were 109.7±72.5cm H2O. The average rate of the wave was 10.9±1.8 times per minute in interdigestive period.3. The shorter the postoperative period was, the shorter the duration of continuous waves was in operated cases.4. The continuous jejunal waves after swallowing were observed more frequently for the cases whose postoperative periods were within two months than for other cases. The waves were thought to be a disadvantage for oral intake.5. Almost all of the continuous jejunai waves after 5 months of postoperative periods were similar to normal interdigestive jejunal strong contractions (interdigestive myo-electric complex; IMEC).From these results and the facts that interdigestive myo-electric complex (IMEC) is not triggered by swallowing and that they disappear immediately after feeding, it is suggested that dysphagia or nasal regurgitation observed in the early postoperative period for the cases of free jejunal transplantation is related to irregular jejunal movements which is different from normal IMEC.

We describe a case of pedunculated hypopharyngeal lipoma with radiographic and endoscopic correlation. This 66-year-old man presented with 3 years of intermittent dysphagia for solids and unrelated episodes of coughing. The literature regarding benign pedunculated polyps of the hypopharynx and proximal esophagus is reviewed. The clinical presentation, diagnostic workup, and recommended therapy for these unusual lesions are discussed.

In 17 ambulatory patients with severe intermittent dysphagia an endoscopic electrosurgical radial incision of a Schatzki ring was made with a modified straight retractable sphincterotome. The incision was successfully accomplished with immediate relief of dysphagia in all patients. Fourteen patients remain asymptomatic with a mean follow-up of 46 months after the first treatment. Three patients required a second incision and they have been asymptomatic for more than 24 months. There was one mild bleeding episode. Endoscopic electrosurgical incision of the Schatzki ring is an effective therapeutic modality in selected patients.

The manometric responses to graded intraesophageal balloon distention were studied in 30 patients with symptoms of intermittent dysphagia but without evidence of structural narrowing on barium swallow or endoscopy, or both. These studies were compared with those performed in 10 normal volunteers. Using a manometric catheter with a balloon of reproducible dimension, balloon distention produced a sustained pressure proximal to the distended esophageal balloon in 28 of 30 (93%) patients and 9 of 10 (90%) normal volunteers. Patients with dysphagia had the reproduction of their characteristic symptom during balloon distention in 23 of 30 (76%) cases. Atypical symptoms not characteristic of the patients' usual dysphagia developed in the other 4 patients with dysphagia and in all controls. There were no electrocardiographic changes during balloon distention and symptoms were immediately reversible with balloon deflation. Repeated simultaneous contractions consistent with spasm distal to the distending esophageal balloon occurred in 21 of 30 (70%) patients with dysphagia but in no normal volunteers (p less than 0.05). Dysphagia reproduction was associated with the finding of repeated simultaneous contractions distal to the intraesophageal balloon being found in 20 of 30 (66%) patients (p less than 0.05). Distal activity during balloon distention of the esophagus is associated with dysphagia reproduction in a significant number of patients without any other explanation for their symptom. The development of distal spasm in patients with intermittent dysphagia suggests an abnormality of neural control that may be important in the pathophysiology of dysphagia in these patients.

SINCE surgical repair of the troublesome lower esophageal ring has not been universally accepted, other modes of treatment have been sought. In 1964, Mossberg reported an excellent result by pneumatic dilatation. Encouraged by this report, pneumatic dilatation was employed in a similar instance with a very gratifying response. Report of a Case A 57-year-old married white male steelworker was admitted to the hospital for the first time in 1958 with the major complaint of intermittent dysphagia since 1955. The episodes of swallowing difficulty did not occur regularly at the same time during the meal. At times, the sensation of food stopping in the lower portion of his chest or upper epigastrium would begin at the very onset of eating, at some times during midmeal, and at others, at the completion of the meal. With the onset of this food sticking sensation, he would become aware of an unpleasant, tight

Intermittent dysphagia due to the presence of an annular constriction in the distal esophagus was reported for the first time in 1953. Ingelfinger and Kramer 1 reported 6 cases of unknown nature and pathogenesis. Schatzki and Gary 2 presented some additional cases a few months later and recognized the presence of this idiopathic concentric narrowing in the distal esophagus as a separate clinical entity. This contractile ring is usually located 3 to 5 cm. from the cardia and reduces markedly the lumen of the esophagus; in some instances the diameter of the esophageal lumen is reduced to only a few millimeters. Endoscopic examination usually fails to reveal any inflammatory changes, scarring, ulceration, or tumor. Barium-swallow studies and esophagograms demonstrate consistently the presence of the ring-like narrowing in the distal esophagus which represents a thin annular diaphragm producing partial obstruction of the esophagus. This condition is usually an incidental finding on