DYSPHAGIA

Ask the following questions:

1. Are there abnormalities on oropharyngeal examination? If so, then of course the cause may be local. This is particularly true if there are painful ulcerations of the mouth, glossitis, or tonsillitis. There may be neoplasms in the oropharynx or larynx that may be either obstructing swallowing or causing pain on swallowing.
2. Is the dysphagia constant or intermittent? Intermittent dysphagia would make one think of myasthenia gravis, and if there are other neurologic findings to suggest that, it would be the most likely working diagnosis. Without neurologic findings, a Schatzki ring may be present.
3. Does the patient have difficulty swallowing both liquids and solids or only solids? If the patient has difficulty with both liquids and solids, a diagnosis of achalasia, scleroderma, or diffuse esophageal spasm should be entertained. Patients who have difficulty swallowing solids only usually should be considered to have esophageal carcinoma until proven otherwise.
4. Is heartburn present? If there is heartburn as well as dysphagia, a diagnosis of reflux esophagitis with or without hiatal hernia should be entertained. Many conditions, including achalasia, diffuse esophageal spasm, and even advanced esophageal carcinoma, may be associated with pain on swallowing or chest pain.
5. Is the patient male or female? Dysphagia in a male is suggestive of esophageal carcinoma; this would be especially true with a history of significant smoking and drinking. Dysphagia in a female would suggest esophageal web, as in Plummer-Vinson syndrome.
6. Is there significant weight loss? Significant weight loss is very often associated with esophageal carcinoma, but not until it is advanced to a significant degree. One often forgets that weight loss is also associated with achalasia.
7. Is there a history of syphilis? Obviously, this would suggest an aortic aneurysm, and in considering aortic aneurysm, one should also consider other mediastinal masses that might be associated with this condition.
8. Are there dermatologic signs and symptoms? This would bring up the possibility of scleroderma.

DIAGNOSTIC WORKUP

In a patient with definite dysphagia, it is wise to consult a gastroenterologist at the outset! The most useful diagnostic test (and most inexpensive) is the barium swallow, and an upper GI series might be done as well. The barium swallow will often display fairly definitive features of carcinoma of the esophagus, esophageal diverticulum, achalasia, hiatal hernia, and esophagitis. The barium swallow, however, must be frequently followed by esophagoscopy to obtain a more definitive diagnosis and a tissue biopsy, particularly in the case of carcinoma of the esophagus. If both of these tests are negative, the possibility of myasthenia gravis should be considered, and a Tensilon test should be done. Esophageal manometry may detect achalasia or diffuse esophageal spasm. When a mediastinal mass is suspected, a CT scan of the mediastinum should be done. When all testing is negative, hysteria should be considered. Ultrasonography can be used to diagnose abnormal movements of the tongue and larynx. Videofluoroscopy is also useful in diagnosing oropharyngeal causes. Reflux esophagitis can be diagnosed with ambulatory pH monitoring. A therapeutic trial of a proton pump inhibitor may be useful.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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