Dysphagia

Dysphagia refers to difficulty in swallowing (distinguish from odynophagia, which refers to painful swallowing). Pathologies that affect voluntary skeletal muscle generally exhibit as difficulty initiating swallowing; if involuntary smooth muscle of the esophagus is affected, sensation of incomplete swallowing tends to occur.

Differential Diagnosis

• Intrinsic esophageal lesions
  –Gastric acid reflux
  –Esophageal webs and rings
  –Radiation-induced inflammation and stricture formation
  –Trauma
  –Esophageal perforation
  –Diverticula
  –Malignancy
  –Postsurgical
  –Foreign body retention

• Extrinsic lesions
  –Anterior cervical osteophyte
  –Mediastinal mass (e.g., thymoma, teratoma, lymphoma, carotid/aortic aneurysm)
  –Post-thoracic surgery or anterior cervical discectomy
  –Enlarged thyroid
  –Thyroglossal duct cyst

• Aberrant motility
  –Hypertensive lower esophageal sphincter
  –Nutcracker esophagus
  –Scleroderma
  –Achalasia
  –Diffuse esophageal spasm (DES)

• Neurological causes
  –Myopathies (e.g., polymyositis, inherited)
  –Neuromuscular junction disorders (e.g., myasthenia gravis, botulism)
  –Polyneuropathies (e.g., diabetic, Guillain-Barré syndrome, toxin-related)
  –Brainstem stroke
  –ALS

• Less common etiologies (“zebras”) include globus hystericus (psychogenic dysphagia), anxiety disorders, hypothyroidism, amyloidosis, dysphagia lusoria (extrinsic esophageal compression due to aortic arch anomalies), left atrial enlargement, and Chagas’ disease

Workup and Diagnosis

• History and physical examination
  –History should include onset, duration, and severity; dysphagia with liquid versus solids; past medical history, including anxiety and other psychiatric illnesses; prior dysphagia or caustic substance exposure; and other head and neck problems
  –Exam should include a thorough head, nose, mouth, neck/thyroid, and abdominal examination, and observation of the patient swallowing
• Oropharyngeal dysphagia: Difficulty initiating swallowing
  –Barium swallow will identify area of swallowing lesion (usually done by speech therapist)
  –EMG/nerve conduction tests to rule out neurologic causes (e.g., myasthenia gravis, ALS)
  –Elevated CPK level suggests muscle disease
  –Brain MRI if CVA is suspected
• Esophageal dysphagia: Sensation of food sticking seconds after initiating swallowing
  –Solids: Barium swallow is less invasive than endoscopy and is frequently sufficient for diagnosis
  –Liquids and/or solids: Esophageal manometry and barium swallow visualization (scleroderma, DES)
• In general, endoscopy and biopsy by a trained gastroenterologist (or surgeon) is necessary for suspected cancer and various therapeutic interventions

Treatment

• Acute mechanical obstructions require urgent endoscopy to relieve the obstruction and prevent potential perforation
• Dysphagia with gastroesophageal reflux disease can be minimized with promotility agents or proton pump inhibitors, weight loss, and avoiding offending foods
• Chronic mechanical obstruction from webs, rings, and strictures require endoscopic treatment or thoracic surgery; balloon dilation may be considered
• Lower esophageal spasm may improve with anticholinergic antispasmodics or the injection of botulinum toxin
• Polymyositis: Glucocorticoids.
• Myasthenia gravis: Muscarinic agents (pyridostigmine), glucocorticoids
• ALS, stroke: Speech therapy evaluation, anticholinergics to prevent saliva aspiration

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X