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DYSPHAGIA                                        229


This is a descriptive term applied to cases usually complaining of a feeling of a
lump in the throat which is brought on or made worse by anxiety and in which
no other organic cause can be found.

Some cases are easy and safe to diagnose as globus—if there is an obvious
emotional precipitating cause. The difficult cases are those in which there is no
obvious psychological cause. Great care must be taken not to miss an early
carcinoma. In this latter group oesophagoscopy must be done in spite of a
negative barium examination.

Globus is diagnosed much less now than formerly, because it has been
realized that oesophagitis and reflex spasm of cricopharyngeus can mimic the
symptoms. In these cases antacids will help the 'globus' symptoms. In the true
globus cases, reassurance that no organic disease or cancer is present helps the
patient to accommodate to the symptoms which will usually be self-limiting.

Another cause of globus-type symptoms is the presence of cervical osteo-
phytes indenting the posterior wall of the pharynx. These can be removed by
exposing them using the same approach as for a pharyngeal pouch.


AETIOLOGY. This is also called *cardiospasm\ and is due to a defect in the
intramural vagal supply (Auerbach's myenteric plexus). During swallowing,
there is a loss of tone due to a lack of integrated parasympathetic stimulation
and non-propulsive motility in the body of the oesophagus. There is also a
failure of relaxation at the cardia.

The lower area acts as a stricture and the oesophagus above this becomes
very dilated and usually full of food debris.

SYMPTOMS. There are few symptoms until the condition is advanced. The
main symptoms are then intermittent difficulty in swallowing associated with
discomfort and attacks of regurgitation. As the condition progresses and
dilatation occurs, food entering the stomach does not initiate peristalsis, and
so large quantities of food collect in the oesophagus. This causes an upset
hi the swallowing mechanism and the condition becomes progressively

On barium swallow the oesophagus is very dilated, lengthened and
occasionally sigmoid in shape (Fig. 117). When the patient is screened the
barium will be seen to be held up for a considerable time and to pass into the
stomach only when the pressure reaches a certain level. At the point of delay
there is no irregularity and the barium emerges centrally as distinct from

TREATMENT. In mild cases treatment with anticholinergic drugs is successful,
but most cases will come to surgery, when a Heller's operation is done,


This injury is not as common in this country as in America, Africa and
Scandinavia. It usually occurs in children or potential suicides and the
substances swallowed are strong acids or alkalis. High concentration or large
volumes of the substance are the most damaging.