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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 12  |  Issue : 3  |  Page : 196-205

Endoscopic evaluation of patients presenting with dysphagia at rural Hospital AVBRH


Department of General Surgery, Jawaharlal Nehru Medical College, DMIMS (DU), Wardha, Maharashtra, India

Date of Web Publication2-Feb-2018

Correspondence Address:
Dr. Siddharth Sahu
Department of General Surgery, Jawaharlal Nehru Medical College, DMIMS (DU), Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_85_17

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  Abstract 


Background and Objectives: Dysphagia refers either to the difficulty someone may have with the initial phases of a swallow (usually described as “oropharyngeal dysphagia”) or to the sensation that foods and or liquids are somehow being obstructed in their passage from the mouth to the stomach (usually described as “esophageal dysphagia”). Upper gastrointestinal GI endoscopy is an important tool in the initial investigation of dysphagia. Endoscopy is indicated in patients with dysphagia to determine the underlying etiology, exclude malignant and premalignant conditions, assess the need for therapy, and perform therapy, such as dilation. Endoscopy-guided biopsy is indicated in structural causes observed during the endoscopic evaluation for confirming the diagnosis with histopathological correlation. Material and Methods: A study of 150 patients who presented with dysphagia, and the study focuses the importance of endoscopic (biopsy when needed) evaluation in these patients. Results: Study shows that the sensitivity of endoscopy was 1.000 (95% confidence interval [CI]: 0.942–1.000), specificity was 0.875 (95% CI: 0.787–0.936). The PPV was 0.849 (95% CI: 0.746–0.922). The NPV was 1.000 (95% CI: 0.953–1.000). Conclusion: Upper GI endoscopy is a safe and effective way to evaluate dysphagia and has both diagnostic and therapeutic value.

Keywords: Dysphagia, esophageal dysphagia, oropharyngeal dysphagia


How to cite this article:
Sahu S, Kher K S, Wagh D D, Swarnakar M, Pandey P, Agnihotri I. Endoscopic evaluation of patients presenting with dysphagia at rural Hospital AVBRH. J Datta Meghe Inst Med Sci Univ 2017;12:196-205

How to cite this URL:
Sahu S, Kher K S, Wagh D D, Swarnakar M, Pandey P, Agnihotri I. Endoscopic evaluation of patients presenting with dysphagia at rural Hospital AVBRH. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2021 Dec 9];12:196-205. Available from: http://www.journaldmims.com/text.asp?2017/12/3/196/224711




  Introduction Top


Dysphagia refers either to the difficulty someone may have with the initial phases of a swallow (usually described as “oropharyngeal dysphagia”) or to the sensation that foods and or liquids are somehow being obstructed in their passage from the mouth to the stomach (usually described as “esophageal dysphagia”). Dysphagia is thus the perception that there is an impediment to the normal passage of swallowed material. Food impaction [1] is a special symptom that can occur intermittently in these patients.

Esophageal dysphagia is frequently encountered in clinical practice.[2] The prevalence of dysphagia in the otherwise healthy general population is difficult to determine but in a recent population-based study focused on dysphagia, it was found that among an adult population, the prevalence of dysphagia was up to 17%, with a peak in the 40–49 years of age group for both males and females, indicating that dysphagia is a remarkably common condition in the general population.[2]

Esophageal dysphagia is the disordered movement of food within the esophagus.[2] It is a common symptom of a number of gastrointestinal (GI) disorders such as benign strictures of the esophagus (peptic, corrosive, and postoperative), malignant strictures of the esophagus, cardia of the stomach, esophagitis (reflux, candidal, or eosinophilic), foreign body in the esophagus, fibrous rings/webs within the esophagus and extrinsic compression of the esophagus.

Recent studies have identified older individuals as being at high risk for dysphagia due to changes in swallowing mechanisms as aging occurs.[3],[4] With the expected doubling of elderly population by the year 2015, dysphagia and its sequel, aspiration pneumonia, are most likely to become a major cause of significant morbidity and mortality. According to a study, it was found that up to 60% of the elderly in long-term care facilities suffer from eating difficulties.[5] Other researchers have estimated the prevalence of dysphagia to be >20% in persons over the age of 50.[6] The medical implications of dysphagia are more readily quantifiable then their social and behavioral counterparts. Dehydration, respiratory infections, and death are all potential medical ramifications of swallowing disorders.

Fiberoptic endoscopic evaluation of swallowing (FEES) is well tolerated and is easy to perform, it is, nevertheless, an endoscopic examination that can result in easily controlled complications such as discomfort, gagging, vomiting, vasovagal syncope, anterior or posterior epistaxis or even dramatic, though rare, and complications such as laryngospasm.[7]

Our hospital caters to the needs of rural population because the patients are poor, socioeconomic status is an important determinant of the planning of investigation and treatment strategies. Economic burden on the patient is not the only factor but going to a far place to get an endoscopic evaluation done is also a point of hesitation for them.

In this study, we aim to find out accuracy of correlate various symptoms and examination characteristics with finding in Upper GI Endoscopy as the reference standard. Thus, we would in the course of this study endeavor to unravel the mysteries in the definitive diagnosis of this common problem more evidence-based, definitive as it is applicable to our situation.


  Materials and Methods Top


Setting

This is a prospective observational study of patients presenting with dysphagia at Acharya Vinoba Bhave Rural Hospital, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, a 1028 bedded tertiary, rural, university-affiliated teaching hospital in central India, from October 2013 to October 2015. Patients from nearby district hospital, primary health centers and private health-care facilities are often referred to AV BRH. Most patients seeking health care at the institute come from neighborhood villages and towns.

Sample size

The sample size was one hundred and fifty patients.

Study design

Participants, inclusion and exclusion criteria

We enrolled patients presenting to the inpatient Departments of Surgery, Medicine, ENT in this study. To be enrolled in the study, patients had to have persistent difficulty in swallowing solids or liquids or both, pain and discomfort in upper abdomen and chest, GERD, blenching, vomiting, or hematemesis. We obtained their informed consent and performed their Upper GI Endoscopy. Endoscopy was done by trained professors in the department with more than 10 years of experience. Every patient enrolled in the study underwent endoscopy; endoscopists were blind to the patient's history and physical examination. Endoscopic-guided biopsy was taken, and patients were subjected to radiological evaluation depending on the indication and needed for evaluating the patient to conclude to a definite diagnosis.

Inclusion criteria for the study

  1. All patients presenting with dysphagia of any age group
  2. Both the sexes
  3. Willing to be a part of the study and willing to undergo advised investigations.


Exclusion criteria

  1. Patient not presenting with dysphagia
  2. Patients unfit for endoscopy and biopsy evaluation
  3. Patients not willing to be a part of this study.


We formulated the research question and sought expertise from the physician to review and fine-tune the research protocol. We reviewed the literature using a large database. We used an electronic spreadsheet (Excel, Microsoft Corp) to enter the data.

The endoscopy was performed by Fujinon Upper GI Endoscopy Unit.

Statistical methods

The data on demographic parameters such as age and gender were expressed in terms of frequency distributions. Furthermore, the mean and standard deviation was obtained for age parameter. The distribution of patients was obtained for behavioral habits such as diet, alcohol and tobacco consumption, and duration of symptoms. The association between age and duration of symptom was also obtained and tested for statistical significance using Pearson's Chi-square. Frequency distribution was also obtained for signs and symptoms of dysphagia, incidence, biopsy status, carcinoma type, and position of pathology. Moreover, the distribution was obtained according to endoscopy and position of pathology. The comparison of endoscopic diagnosis with biopsy findings was performed to compute the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of endoscopy for detecting carcinoma.


  Observation and Results Top


The mean age of cases was 53.48 years with a standard deviation of 14.95 years.

The male to female ratio was 127 males per 100 females.

There were 38 (45.24%) males having both habits of alcohol and tobacco consumption. No females enrolled in the study gave a history of alcohol consumption [Table 1] and [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16].
Table 1: Distribution of cases according to both alcohol and tobacco (n=84)

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Figure 1: Bar chart showing the distribution of cases as per age

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Figure 2: Pie chart showing the distribution of cases as per gender

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Figure 3: Pie chart showing the distribution of cases as per diet

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Figure 4: Pie chart showing the distribution of cases as per alcohol consumption in males. No females enrolled in the study gave a history of alcohol consumptionrepresentation

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Figure 5: Bar chart showing the distribution of cases as per tobacco and gender

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Figure 6: Pie chart showing the distribution of cases as per duration of presentation of dysphagia

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Figure 7: Bar chart showing the distribution of cases as per age and duration

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Figure 8: Bar chart showing the distribution of cases as per dysphagia

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Figure 9: Bar chart showing the distribution of cases as per endoscopic evaluation. (n = 150) Few cases showed multiple causes of dysphasia on upper GI endoscopy

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Figure 10: Bar chart showing the distribution of cases as per incidence

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Figure 11: Bar chart showing the distribution of cases as per biopsy status

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Figure 12: Bar chart showing the distribution of cases as per carcinoma type

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Figure 13: Bar chart showing distribution of cases as per age and incidence of carcinoma

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Figure 14: Bar chart showing distribution of cases as per gender and incidence of carcinoma proven on endoscopic guided biopsy

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Figure 15: Bar chart showing the distribution of cases as per position of pathology

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Figure 16: Bar chart showing distribution of cases as per endoscopy and position of pathology

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A comparison of endoscopy diagnosis with biopsy results was performed as shown in [Table 2]. There were 62 (84.93%) cases, which were diagnosed as carcinoma by endoscopy and were confirmed on endoscopic guided biopsy (true positives). There were 77 (100%) cases diagnosed as negative for carcinoma by both endoscopy and biopsy methods (true negatives). There were 11 (15.07%) cases, which were diagnosed as carcinoma using endoscopy, but were noncarcinoma cases as observed through biopsy (False Positives). Out of total 73 diagnosed cases of carcinoma by endoscopy, 3 cases were of adenocarcinoma stomach (cardiac end). There was no case which was diagnosed as carcinoma on biopsy and was not reported as carcinoma on endoscopic evaluation (False Negatives). A bar chart representation of the distribution of cases as per endoscopy and biopsy diagnosis is shown in [Figure 17].
Table 2: Comparison of endoscopy diagnosis with biopsy

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Figure 17: Bar chart showing comparison of endoscopy diagnosis with biopsy diagnosis

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Accordingly, the statistical parameters such as sensitivity and specificity of endoscopic diagnosis were determined with the results shown in [Table 3]. It shows that the sensitivity of endoscopy was 1.000 (95% confidence interval [CI]: 0.942–1.000), however, specificity was 0.875 (95% CI: 0.787–0.936). The PPV was 0.849 (95% CI: 0.746–0.922). The NPV was 1.000 (95% CI: 0.953–1.000).
Table 3: Statistics providing comparative evaluation of endoscopy and biopsy

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[Table 4] summarizes that there were 43 cases diagnosed as esophagitis based on endoscopic guided biopsy. Out of these, 33 cases were diagnosed as esophagitis on endoscopy, while 10 cases were diagnosed with carcinoma on endoscopy, which were diagnosed as esophagitis on biopsy [Table 5], [Table 6], [Table 7].
Table 4: Comparison of endoscopy diagnosis with biopsy results for esophagitis

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Table 5: Comparison of gender disparity in dysphagia of present study with other studies

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Table 6: Comparison of duration of symptoms in dysphagia of present study with other studies

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Table 7: Comparison of analysis parameters for endoscopic evaluation with biopsy in dysphagia of the present study with other studies

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  Discussion Top


Dysphagia may result from structural or neuromuscular disorders of the esophagus. Patients with structural disorders of the esophagus typically have dysphagia with solids alone, in contrast to patients with motility disorders who present with both liquid and solid food dysphagia.[8]

Dysphagia contributes to a variety of negative health status changes; most notably, increased risk and respiratory complications such as aspiration pneumonia and airway obstruction.[9]

Upper GI endoscopy is an important tool in the initial investigation of dysphagia.[10] Endoscopy is indicated in patients with dysphagia to determine the underlying etiology, exclude malignant and premalignant conditions, assess the need for therapy, and perform therapy, such as dilation. Endoscopy guided biopsy is indicated in structural causes observed during the endoscopic evaluation for confirming the diagnosis with histopathological correlation.

Age factor

Dysphagia is a growing health concern in our aging population. Age-related changes in swallowing physiology as well as age-related diseases are predisposing factors for dysphagia in the elderly. In our study of 150 patients, maximum number of patients, i.e., 45% belonged to the 41–60 years age of group and next 30% belonged to above 60 years age group.

This is mainly due to swallow physiology changes with advancing age. Reductions in muscle mass and connective tissue elasticity result in loss of strength and range of motion.[11],[12] These age-related changes can negatively impact the effective and efficient flow of swallowed materials through the upper aerodigestive tract.[9] In World Gastroenterology Organisation Practice Guidelines, have mentioned that dysphagia occurs in all age groups but its prevalence increases with age.[13]

Gender disparity

In our study patients, the ratio of dysphagia cases among male (56%) and female (44%) patients was observed to be 1.27:1. Very similarly in a study by Qureshi et al., a total of 913 patients with dysphagia were included in their study which included 465 males (age range: 17–92 years, median: 64 years) and 448 females (18–100 years, median: 67 years), with male to female ratio of 1.04:1.[14]

Quite contrary to our findings in a study by Wilkins et al., out of total 214 cases of dysphagia, 173 were female cases, while only 41 were male cases (80.8% women vs. 19.2% men, P = 0.002). In the absence of any biological explanation for this gender difference, it may be explained by the similar greater likelihood of women than men to report GI symptoms.[15]

Type of diet

Out of 150 cases of dysphagia in our study, 56% patients were taking nonvegetarian diet while 44% patients were pure vegetarian. Although the difference was not much significant, still type of food intake can affect the digestive system.

Shah et al., in their study also mentioned a similar observation in which 50% cases had spicy and oily food and 46% had nonvegetarian diet.[17]

Alcohol and tobacco consumption

Alcohol and tobacco are considered as one of the main causing factors of morbidity and mortality.[18],[19] Out of total 84 male patients in our study, 51 consumed alcohol, 57 were habituated to tobacco smoking/chewing, and 38 were addicted to both alcohol and tobacco consumption. Although in our study no female alcohol-consuming patients was enrolled, out of 66 female patients, 28 were having a habit of tobacco smoking/chewing.

As mentioned in the guidelines for the management of gastroenterological diseases (Ministry of Health and Family Welfare Govt., of India), esophageal cancers have been associated with alcohol consumption, obesity and smoking counseling about avoiding these risk factors might be useful.

Similar to our findings, a study by Kishve et al., also observed male preponderance (61% males; 39% females) in their study which may be due to the more exposure of this gender to alcohol intake, smoking, tobacco, and pan masala chewing.[20]

Duration of symptoms

The symptoms start appearing in the patients well from starting but they pay attention only when the other complications arise or the symptoms get worse. In our study, the maximum numbers of patients were those in whom the symptoms were present for more than 6 months.

Similar to our observation, in a study by Khan et al., most of the patients, i.e., 53.2% were having dysphagia for more than 24 weeks.[21] The minimum duration of dysphagia noted was 4 weeks while the maximum duration of dysphagia was 78 weeks. From this Khan et al. made an inference that malignancy is an important cause of dysphagia in the elderly males having dysphagia for a prolonged duration. According to the review done by Cook on the diagnosis of dysphagia, a short history of dysphagia particularly with rapid progression (weeks or months) and associated weight loss is highly suggestive of esophageal cancer.[22] Long-standing, intermittent, nonprogressive dysphagia purely for solids is indicative of a fixed structural lesion such as a distal esophageal ring or proximal esophageal mucosal web.

Symptoms of dysphagia

Patients with malignant tumors of the upper GI tract tumors exhibit important alarm symptoms such as dysphagia that warrant clinical investigations. In our study subjects, 60% cases were having difficulty in swallowing solid foods while 40% were having both solid and liquid swallowing difficulty. No cases of liquid alone was found as patients who were having difficulty in swallowing liquid were facing simultaneously same difficulty with solid food as well. Dysphagia that occurs equally with solids and liquids often involves an esophageal motility problem.

Other main symptoms included weight loss (53%), vomiting (51%), and heartburn (31%). One of the main apparent reasons for weight loss was loss of appetite (67%).

In the study by Wilkins et al., of the patients who reported dysphagia, 49.0% reported problems swallowing with solids only, 6.3% with liquids only, and 44.7% with both solids and liquids.[15]

Endoscopic evaluation

FEES is well tolerated and is easy to perform, it is, nevertheless, an endoscopic examination that can result in easily controlled complications such as discomfort, gagging, vomiting, vasovagal syncope, anterior or posterior epistaxis or even dramatic, though rare, and complications such as laryngospasm.[7],[23]

Endoscopy is indicated in patients with dysphagia to determine the underlying etiology, exclude malignant and premalignant conditions and assess the need for therapy. Endoscopic evaluation in our study subjects showed that the maximum number of cases were of Ca esophagus (47%) followed by esophagitis in 22% cases.

The incidence of esophageal cancer is moderately high in most parts of India. It is the third leading cause of death in men and fourth leading cause in women.[24]

Incidences of dysphagia

In our study group, the maximum number of incidences, i.e., approximately 16% of medical cause and 80% was due to the surgical causes especially 47% due to esophagus carcinoma, followed by esophagitis (22%).

According to Absi et al., dysphagia is the most common manifesting symptom of esophageal cancer which usually develops in response to dense solid food, and progresses gradually to interfere with the intake of softer foods and finally, liquids. Dysphagia is an alarming symptom that merits careful evaluation for the possibility of esophageal cancer (Ahmed Absi, David J. Adelstein, Thomas Rice, Disease Management, August 2010).[25]

Nurko and Furuta in their review on esophagitis (GI Motility online (2006)) have confirmed that dysphagia is one of the most common presenting symptoms of esophagitis.[26] According to them, although the symptom of dysphagia is usually longstanding, it is often intermittent, not interfering with daily life.

Other surgical causes included poisoning (2%), stomach cancer (2%), and hiatus hernia (3%). Hiatal hernia is a condition in which parts of the abdominal contents, mainly the GEJ and the stomach, are proximally displaced above the diaphragm through the esophageal hiatus into the mediastinum.[27] Dysphagia may occur as a result of compression of the esophagus within the hiatus by the herniated portion of the stomach or by gastric volvulus.[28]

Among the total 16% medical causes of dysphagia, stroke was contributing factor in 7% cases followed by  Parkinsonism More Details in 3% cases. Wilkins et al., 2007 in their study also found that medical conditions of predisposing patients to dysphagia include stroke, Alzheimer disease, amyotrophic lateral sclerosis, and Parkinson's disease.[15] Patient who had undergone previous endoscopic band ligation for esophageal varies with portal hypertension presented with dysphagia. As literature suggests large number of patients complain of postendoscopic variceal ligation pain and mild-to-moderate degree of dysphagia.

Achalasia cardia was also found as a contributor to dysphagia in 3% cases. Achalasia is an esophageal motor disorder characterized by aperistalsis of the esophageal body and lack of relaxation of the lower sphincter in response to swallows. It affects both sexes and all age groups.[29],[30] Kaufman et al. also stated in his review in nature that the hallmark symptom of achalasia is progressive dysphagia, often first to solids and then to liquids. Because the dysphagia usually worsens very gradually, it is often quite severe on presentation.[31]

Last but not the least, tracheostomy was found as the traumatic cause of dysphagia in our study in more than 7% cases. A tracheotomy or a tracheostomy is an opening surgically created through the neck into the trachea to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. In our study, patients who had a history of tracheostomy due to ventilator support postoperatively, stroke or posthead injury was found to have dysphagia. In a study conducted by Macht et al., 2011, it was found that one of the statistically significant (P≤ 0.01) risk factors for severe dysphagia is tracheostomy which was present in 50 out of 179 moderate or severe dysphagia cases.[32]

Carcinoma types

Out of total 62 cases of carcinoma in our study, 49, i.e., 79% were detected as squamous cell carcinomas (SCCs) and the rest 13 cases, i.e., 21% were adenocarcinoma. SCC is the predominant histologic type of esophageal cancer worldwide.[33] Cherian et al., 2007 also stated in their study that SCC was the most common malignancy, seen in 912 (92%) patients.[34]

Age and incidence of carcinoma

In our study group, the patients in the age group 41–60 showed maximum incidence of carcinoma, i.e., 53% of total cases.

Shil et al. observed that esophageal carcinoma was seen in sixth (51–60 years) decade of life followed by seventh and fifth decades. Population-based data reveal that the esophageal cancer incidence peaks in the sixth decade as in most parts of the world.[35]

For different types of esophageal cancer, the risk increases with age, with a mean age at diagnosis of 67 years.[33]

Gender and incidence of carcinoma

From our data, it was observed that the carcinoma cases were more in males as compared to females though the ratio difference is not so significant 1.13:1.

Many earlier studies have stated that esophageal cancer is 4 times more common and slightly more lethal in men than in women.[36] Puhakka and Aitsalo, Malik et al., Afridi et al., and Salih et al. reported a high ratio of males for this cancer as compared to females.[37],[38],[39],[40]

Esophageal cancer predominantly affects male gender; difference in carcinoma cases is entirely explained by the higher prevalence of risk factors such as tobacco smoking and obesity in men.[41] SCC is 2-3 times more common in males than females in low-risk areas of the world whereas these ratios become equal in some of the regions of China and Iran, known as high-risk areas [42] (Munoz et al., 1996).[43]

Although there are studies in which contrary results are also obtained. Bukhari et al., in their study showed the predominancy of females 57% in esophageal cancers as compared to males 43%.[44] These results are in favor of findings by Bhurgri et al. who reported a rising incidence for esophagus cancer in females. Bhurgri et al.,[45] also in their study, found esophageal tumors to be 2 times more common in females than males in contrast to the literature.[46] While Roohullah et al. reported a similar frequency of this cancer in both sexes without any disparity in both the sexes as observed in our observational study.[47]

Endoscopy and position of pathology

The SCC is presenting mostly in the upper 2/3 of the esophagus. Adenocarcinomas mainly arise in the distal third and gastroesophageal junction (Toni Lerut; Carcinoma of the esophagus and gastroesophageal junction).[48]

An endoscopy is commonly done when people first present with symptoms. Using endoscopy, the area of concern in the esophagus can be viewed directly with the fiber optic camera, and the location of the abnormality, the presence or absence of bleeding, and the amount of obstruction can all be seen. Endoscopy also allows a biopsy to be performed. Once a biopsy is performed, the pathologist can determine if there is any evidence of inflammation, esophageal cancer, and whether it is adenocarcinoma or SCC.

In our study, biopsy was performed in 109 cases. Out of 73 suspected carcinoma cases, in our study, biopsy was performed in 109 cases. Out of 73 suspected carcinoma cases by endoscopy, 70 cases of carcinoma esophagus and 3 suggestive of carcinoma stomach cardiac end. Sixty-two were confirmed by biopsy while rest 10 suggestive of esophagitis and 1 case suggestive of inflammatory infiltrate/gastritis taken from the cardiac end of the stomach. Thus, endoscopy showed 100% sensitivity, 87.5% specificity, 100% NPV, and 85% PPV.

In a study by Nagai et al., 2014 the accuracy of endoscopic diagnosis and biopsy diagnosis was 91.0% (101/111) and 85.6% (95/111) in case of esophageal carcinoma.[52]

There were 62 (84.93%) cases, which were diagnosed as carcinoma by endoscopy and were confirmed on endoscopic-guided biopsy (True Positives). There were 77 (100%) cases diagnosed as negative for carcinoma by both endoscopy and biopsy methods (True Negatives). There were 11 (15.07%) cases, which were diagnosed as carcinoma using endoscopy, but were noncarcinoma cases as observed through biopsy (False Positives). Out of total 73 diagnosed cases of carcinoma by endoscopy, 3 cases were of adenocarcinoma stomach. There was no case which was diagnosed as carcinoma on biopsy and was not reported as carcinoma on endoscopic evaluation (false negatives).

Comparison of endoscopy diagnosis with biopsy results for esophagitis

Esophagitis is the inflammation of esophagus. Esophagitis damages the esophagus tissue. Esophagitis that remains untreated can lead to changes in the function of the esophagus, as well as its structure. In our study, out of 43 cases, 33 were detected as esophagitis by endoscopy while. When biopsy was performed all 43 cases were confirmed as esophagitis (10 cases were diagnosed as carcinoma on endoscopic evaluation which turned out to be suggestive of esophagitis).


  Summary Top


Dysphagia most common in the fifth and sixth decade of life with mean age group of 53.48 male gender with a greater predilection to dysphagia due to lifestyle habit in our population, i.e., consumption of alcohol and tobacco. Dietary habits of consuming nonvegeterian and spicy diet are a predisposing factor. Out of 150 patients, 81 patients approached late with their complaints. Patients who presented late were observed to have advanced malignancy. Structural causes of dysphagia accounted for around 80% followed by medical cause 16% (on the basis of history, clinical, radiological, and laboratory evaluation) and 4% other causes. Structural causes of dysphagia are best evaluated through Upper GI endoscopy with biopsies whenever aided for histopathological diagnosis and in cases of dilemma of diagnosis is observed. Among structural causes, carcinoma esophagus was the leading cause of dysphagia followed by esophagitis. Patients if present early with their complaints can undergo early evaluation and receive the appropriate treatment according to the etiology rather than presenting late with malignant transformation over time and therefore an increase in morbidity and mortality. These patients were observed to be inoperable. As per endoscopic guided biopsy evaluation there were 43 (39.45%) cases of esophagitis with 13 (30.23%) cases of lower one-third position, 13 (30.23%) cases of lower two-third position, 2 (4.65%) cases of middle position, 8 (18.6%) cases of upper position, and 7 (16.28%) cases of whole length. There were 59 (54.13%) cases of Ca esophagus, while 3 (2.75%) cases of Ca stomach cardiac end, and 4 (3.67%) cases of stomach biopsy s/o inflammatory infiltrate/gastritis.


  Conclusion Top


Upper GI endoscopy is an effective and appropriate initial investigation to assess patients with dysphagia, especially above the age of 50 years with or without additional symptoms such as weight loss, heartburn, and vomiting. This study would recommend taking multiple biopsies in any abnormal looking upper GI mucosa to reach a safe and definite diagnosis, will help in making a provisional diagnosis in most cases and biopsies can be taken from the suspected lesions to get histological evidence. At the same time, patients may be started on treatment for benign but potentially harmful conditions such as gastroesophageal reflux disease. Patients may also be referred for further investigations in the absence of any anatomical abnormality in cases of dysphagia. Radiological studies such as fluoroscopy or Barium swallow/meal and manometry study may explain any motility disorders in cases of normal endoscopy findings of the upper GI tract. Upper GI endoscopy is a gold standard tool for evaluation of patients with dysphagia due a structural cause. Dysphagia may be associated with serious underlying disorders such as esophageal or gastric carcinoma. The evaluation of dysphagia remains incomplete without upper GI endoscopy which should be considered at the earliest, especially in the elderly having dysphagia of medium to long-term duration to diagnose the treatable conditions such as reflux esophagitis or esophageal carcinoma at an early stage. Upper GI endoscopy is a safe and effective way to evaluate dysphagia and has both diagnostic and therapeutic value.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


This article has been cited by
1 Clinical profile of patients presenting with dysphagia - an experience from a tertiary care center in North India
Tuhin Mitra,Vinod K Dixit,Sunit K Shukla,Dawesh P Yadav,Piyush Thakur,Ravi K Thakur
JGH Open. 2019;
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