A case to anchor the episodeA 55-year-old woman has twelve months of progressive dysphagia to solids and liquids, regurgitation of undigested food, nocturnal cough, and weight loss. EGD shows a dilated body with residue and a junction that passes with gentle pressure, no mass, biopsies unremarkable. The story is classic achalasia. Do you proceed to myotomy? Dysphagia is the symptom that anchors the esophagus chapter, and the whole game is getting to the right test on the first move. Fix the vignette to one quadrant of a two-by-two, anatomy against mechanism, and the test selection falls out of the sort rather than being memorized. This episode builds that grid, then stress-tests it against the alarm-feature framework and the cases that break a careless read. Topics coveredTwo axes: oropharyngeal versus esophageal, mechanical narrowing versus motilityLocalization: throat plus airway symptoms versus substernal sticking after the swallowOropharyngeal causes are neuromuscular: stroke, Parkinson, ALS, myasthenia, radiationModified barium swallow with a speech pathologist reads the swallow itself; EGD cannotSolids-only progressive: ring, web, peptic stricture, EoE, malignancySolids-and-liquids from the start: achalasia, spasm, jackhammer, sclerodermaEGD with two-level biopsies even on normal-looking mucosa, because EoE is histologicBarium esophagram and high-resolution manometry as the second-line motility testsAlarm features raise malignancy pretest probability; they do not decide whether to scopeZenker diverticulum: barium first so the scope does not perforate the pouch Key decisionsNew dysphagia is itself an alarm symptom: a 35-year-old with solid-food dysphagia still gets EGD; the over-50 cutoff is a dyspepsia rule, not a dysphagia ruleThroat plus cough, nasal regurgitation, or drooling routes to modified barium swallow, not EGD; EGD sees mucosa, not the swallowing maneuverSolids-only that progresses over months with weight loss in an older patient is esophageal cancer until proven otherwiseA classic achalasia story still needs manometry before a myotomy: subtype changes the procedure, and pseudoachalasia from a cardia tumor mimics the pictureBorderline manometry (IRP just over cutoff, no pressurization) is inconclusive: FLIP or timed barium before the operating room, not a myotomy For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.Questions or feedback: [email protected]. (00:00) - Opening: the two axes of dysphagia (01:30) - Localization: where the patient points (03:30) - Oropharyngeal dysphagia and the modified barium swallow (06:00) - Esophageal dysphagia: reading the pattern (08:30) - EGD with biopsies as the workhorse first test (11:00) - The alarm-feature framework and the age-cutoff trap (13:30) - Zenker diverticulum: why barium leads (16:00) - The case that does not fit: manometry before myotomy (19:00) - The algorithm in a handful of moves

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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