You are on page 1of 9



A D VA N C E S I N C L I N I C A L P R A C T I C E jgh_7097 873..881

Current and future techniques in the evaluation

of dysphagia
Paul Kuo, Richard H Holloway and Nam Q Nguyen
Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia

Key words Abstract

dysphagia technique, endoscopy: upper
gastrointestinal, esophageal motility,
Dysphagia is common in the general population, and is generally due to either mechanical
esophagus. obstruction or dysmotility. Patient demographics and symptom evaluation are often useful
in determining the likely cause, and guide subsequent investigation and management.
Accepted for publication 23 January 2012. Oropharyngeal dysphagia is usually caused by neurological conditions where treatment
options are limited. Conversely, many of the esophageal causes of dysphagia are amenable
Correspondence to therapy. Gastroscopy is often the first test of choice, given its diagnostic and therapeutic
Dr Nam Nguyen, Department of potential, especially when mechanical causes are concerned. Esophageal motor function
Gastroenterology and Hepatology, Royal can be assessed by a variety of techniques, ranging from radiology such as barium swallow,
Adelaide Hospital, North Terrace, Adelaide, to dedicated motility tests such as manometry and impedance monitoring. The choice of
SA 5000, Australia. Email: test relies on the clinical indication and the results should be interpreted in conjunction with the patients symptoms. High-resolution manometry with topography is now the new
benchmark for motility studies. Several new techniques for motility testing have also
become available, such as esophageal ultrasound and functional lumen imaging probe, but
are currently limited to the research setting.

the feeling of food/drink sticking, or a discomfort either in the

Introduction throat or retrosternally, or simply being able to sense the act of
Dysphagia, or difficulty in swallowing, affects up to 22% of swallowing; occasionally, regurgitation, aspiration, or even hiccup
patients in the primary care setting,1 and represents one of the most may be the presenting complaint.2
common reasons for referral to gastroenterologists. While the The most important first step in assessing dysphagia is to deter-
history is the most important part of clinical assessment, bedside mine whether it is oropharyngeal or esophageal in origin, as their
assessment alone is often inadequate in achieving a diagnosis. potential causes and subsequent investigation and management
Further testing is therefore usually required and may include can differ greatly. This can usually be achieved through taking a
barium swallow, upper gastrointestinal endoscopy and, where careful history, which has been shown to accurately differentiate
available, esophageal manometry. More recently, several new tests between oropharyngeal, esophageal, and neuromuscular causes of
have become available for esophageal motility assessment, dysphagia in up to 85% of patients.3 It is important to know if the
although their utility in the clinical setting remains to be estab- dysphagia is present only during swallowing or at all times, the
lished. Nevertheless, these new techniques offer the opportunity to latter suggests potential sensory dysfunction, and the most
provide further insights into various motility disorders, thus to common disorder is globus hystericus. Dysphagia that occurs only
improve our understanding of these diseases and, hopefully, lead during swallowing of solids is more likely to indicate underlying
to identification of new therapeutic targets. This paper aims not mechanical obstruction, whereas when both solids and liquids are
only to review the current clinical and laboratory assessments of affected, dysmotility is the likely cause. The presence of symp-
dysphagia but also the emerging techniques that have been devel- toms such as delayed or absent swallow initiation, cough post-
oped recently that allow better understanding of esophageal motor swallowing, nasopharyngeal regurgitation, and repeated swallows
function. to effect pharyngeal clearance, indicate potential oropharyngeal
Localization of the hold-up site based on symptom is not always
Clinical assessment a reliable guide to the site of the obstruction.2,4 However, dysph-
Dysphagia is a very non-descriptive term that can result from any agia felt in the throat is more likely to be oropharyngeal in origin
problem arising between the posterior oral cavity and the proximal as compared with that in the retrosternal region, which is more
stomach. The term also gives no clue as to whether the problem is suggestive of an esophageal disorder. The duration and progres-
primarily a motor or sensory one. Typically, patients complain of sion of symptoms are also important features. Chronic and stable

Journal of Gastroenterology and Hepatology 27 (2012) 873881 873

2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Evaluation of dysphagia P Kuo et al.

symptoms suggest benign conditions such as peptic strictures or Table 1 Causes of oropharyngeal dysphagia. (adapted from Cook IJ,
Schatzkis ring, while rapidly progressive symptoms, especially in 20092)
association with weight loss, indicate a more sinister cause. The
Central nervous system Drugs
presence of regurgitation immediately after swallowing suggests Stoke Centrally acting
esophageal retention of food, whereas regurgitation in between Extrapyramidal syndromes Phenothiazines
meals indicates the presence of a pharyngeal pouch or Zenkers (Parkinson, Huntington, Metoclopramide
diverticulum. Wilsons) Benzodiazepines
Dysphagia that occurs after a long history of reflux symptoms, Brainstem tumors Antihistamines
especially with patients giving a history of poor symptom control, Alzheimers Drugs acting at neuromuscular
may suggest the development of complications such as peptic Motor neurone disease junction
stricture, Barretts esophagus and possibly, esophageal adenocar- Peripheral nervous system Botulinum toxin
cinoma. Patients with known esophageal dysmotility often have Spinal muscular atrophy Procainamide
volume reflux, and throat irritation caused by reflux can induce the Guillain-Barre Penicillamine
sensation of dysphagia. In young patients who present with dys- Post-polio syndrome Erythromycin
phagia or food bolus obstruction, especially those with a history of Myogenic Aminoglycosides
atopy, eosinophilic esophagitis must be suspected and esophageal Myasthenia gravis Drugs toxic to muscle
biopsies must be performed on subsequent gastroscopy. Polymyositis/dermatomyositis, Amiodarone
Dysphagia may be a complication of systemic disease or medi- inclusion body myositis Alcohol
cation. Oropharygenal dysphagia is common in patients with a Thyrotoxicosis HMG-CoA reductase inhibitors
Paraneoplastic syndrome Cyclosporin
history of head and neck surgery or radiotherapy, stroke and other
Structural disorders Penicillamine
neurological conditions such as Parkinsons disease and motor
Zenkers diverticulum Miscillaneous, presumed
neuron disease. A detailed neurological examination would, there-
Cricopharyngeal bar or stenosis neuromyopathic
fore, be an important part of the clinical evaluation of orophagy-
Cervical (mucosal) web Digoxin
ngeal dysphagia. It is equally important to look for peripheral skin
Oropharyngeal tumor Trichloroethylene
and joint stigmata of scleroderma, CREST syndrome or systemic Head and neck surgery Vincristine
connective tissue disease, as these patients are at risk of esoph- Radiotherapy Drugs inhibiting salivation
ageal hypomotility. Medications such as dopamine antagonists and Anticholinergics
anti-cholinergic agonists can lead to xerostomia and esophageal Antidepressants
dysmotility. The presence of xerostomia should be enquired, as Antipsychotics
treatment is simple and effective. In elderly patients, pill-induced Antiparkisonian drugs
ulceration and stricture should be suspected for those who take Antihypertensives
bisphosphonates and non-steroidal anti-inflammatory drugs. Diuretics
Finally, risk factors for esophageal and gastric cancers such as
smoking, alcohol use, ethnic background and known family
history of upper gastrointestinal (GI) malignancy should be noted.
lower esophageal sphincter, leading to anatomical obstruction.
Tumors in the region of the lower esophageal sphincter or gastric
Oropharyngeal dysphagia cardia can give rise to pseudo-achalasia with identical clinical
It is important to remember that although healthy aging is related presentation. Eosinophilic esophagitis has recently been recog-
to certain neuromuscular changes, it rarely leads to clinically sig- nized as an increasing common cause of dysphagia and food bolus
nificant dysphagia.2 Therefore, the presence of oropharyngeal dys- impaction. Histologically, eosinophilic esophagitis is character-
phagia will always require a search for an underlying cause ized by marked eosinophilic infiltration and associated inflamma-
(Table 1). The biggest clue to the cause of a patients oropharyn- tion in the esophagus and, in patients with longstanding disease,
geal dysphagia lies with age. Development of oropharyngeal dys- marked fibrosis of the esophageal wall. This, in turn, can lead to
phagia in an elderly person (age > 70 years) may relate to either an significant stiffening, luminal narrowing, and impaired peristal-
acute neurological event such as a stroke, or a progressive neuro- sis of the esophagus. The diagnosis of this condition heavily
logical disease such as Parkinsons disease and Alzheimers. relies on clinical awareness, endoscopic features and esophageal
Zenkers diverticulum is also more prevalent in the elderly. In biopsies.
contrast, degenerative motor neuron diseases must be suspected in
younger patients.
General approach to investigation
Accurate identification of the cause of dysphagia usually requires
Esophageal dysphagia
investigations that can be broadly divided into imaging and motil-
The causes of esophageal dysphagia can be broadly divided into ity assessment. The main aims are to exclude a potentially fatal
either mechanical or dysmotility (Table 2). There are, however, a pathology such as cancer, and to identify a potentially treatable
number of conditions in which dysphagia is mediated by both cause. The choice of test(s) depends largely upon the perceived
mechanical and dysmotility mechanisms. Achalasia is a classic underlying cause, as the sensitivity and specificity of each test
example of such a condition, where there is often a failure of differs depending on the underlying condition, in large part
peristalsis in the esophageal body with impaired relaxation of the because of the inherent capability of the technique. Given the

874 Journal of Gastroenterology and Hepatology 27 (2012) 873881

2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
P Kuo et al. Evaluation of dysphagia

Table 2 Causes of esophageal dysphagia: mechanical versus over recent decades, having progressed from single-channel
dysmotility manometry to the modern day 36-channel high-resolution manom-
etry with topography,5 impedance monitoring,6,7 planimetry,8,9 and
Mechanical Dysmotility
intraluminal ultrasound.10 However, each of these techniques is
Benign strictures Achalasia only designed to measure one out of three important aspects of
Peptic stricture Diffuse esophageal spasm esophageal motor function assessment namely, muscular contrac-
Schatzkis ring Eosinophilic esophagitis tile activity, intraluminal pressure, and bolus transit. To overcome
Webs Reflux esophagitis and this, a combined approach incorporating more than one technique
Post-surgical or anastomosis Barretts esophagus is being increasing adopted.
Caustic injury
Radiation injury
Eosinophilic esophagitis Current techniques for assessing
Extrinsic compression (e.g. benign dysphagia
inflammatory mediastinal lymph
node, spine osteophyte, vascular Barium swallow
External compression e.g. large The barium swallow remains a widely available and relatively
Zenkers diverticulum, cardiac inexpensive first-line investigation for dysphagia. It remains
or pulmonary mass attractive in those who are either poorly tolerant of, or unfit to
Post fundoplication undergo, other procedures, such as gastroscopy. Fluoroscopy
Malignant strictures offers real-time and continuous viewing of the bolus during transit
Squamous cell carcinoma from the oropharynx into the stomach, and transit of both liquid
Adenocarcinoma and solid boluses should be evaluated. It is non-invasive and pro-
Extrinsic compression (e.g. vides a good qualitative and potentially quantitative functional
malignant mediastinal lymph node, assessment of the esophagus, including the upper and lower esoph-
lung cancer, lymphoma) ageal sphincters. Barium swallow may also demonstrate any
obvious anatomical abnormality including stricture, Schatzkis
ring, and mass lesion. Additional advantages include its wide
availability compared with other more specialized techniques, and
differences in the causes as well as the anatomical structures lower cost. It is therefore a useful first investigation for dysphagia.
responsible for oropharyngeal and esophageal dysphagia, the However, barium swallow is operator and interpreter dependent.
approaches for their investigation are different. While it has poor sensitivity for subtle abnormalities and entails
exposure to ionizing radiation, it is more sensitive in detecting
Oropharyngeal dysphagia esophageal webs and rings than gastroscopy.
It has been proposed that a timed barium swallow (TBE) is
Available diagnostic tests include standard barium swallow, useful for assessing the response to treatment of achalasia. Fol-
modified barium swallow, nasoendoscopy, and pharyngeal lowing either myotomy or pneumatic dilatation, the height of
manometry. Modified barium swallow is carried out by both a the barium column at 1 min post-contrast ingestion 6 months
radiologist and speech pathologist. It offers real-time assessment after treatment was found to correlate with symptom scores.
and recording of oropharyngeal coordination and the presence Conversely, a lack of TBE improvement predicted treatment
and extent of aspiration, and allows instant feedback on the effect failure.11
of swallowing maneuvers and posture. Nasoendoscopy, also
known as fiber optic endoscopic examination of swallowing, not
only allows direct visualization of lingual, pharyngeal, and epig- Upper endoscopy
lottic movements during swallowing but also assesses the pres- Upper GI endoscopy, often known as gastroscopy, not only pro-
ence of any pharyngeal retention of liquids or solids after vides direct visualization of the esophagus but also the oro-
swallowing. Pharyngeal manometry is particularly useful in pharynx, stomach and duodenum. For many patients, especially
detecting failure of upper esophageal sphincter relaxation, the those with a history that is suggestive of a mechanical obstruction,
presence of which indicates potential therapeutic benefit with cri- gastroscopy is the preferred first-line investigation. It is particu-
copharyngeal myotomy or dilatation, although evidence for this is larly useful in identifying intraluminal mass lesions, strictures and
largely anecdotal. inflammatory disorders such as reflux disease, eosinophilic esoph-
agitis, and pill-induced ulceration.
In addition to the ability to take mucosal biopsies to confirm a
Esophageal dysphagia
histological diagnosis, the major advantage of gastroscopy is its
Mechanical causes, such as an obstructing mass lesion or stricture, therapeutic potential. Although eosinophilic esophagitis classi-
are predominantly identified during gastroscopy, while motility cally presents as linear furrows, circular rings, ulceration or stric-
disorders such as achalasia and spasm are diagnosed by manom- turing of the esophagus on gastroscopy (Fig. 1), a significant
etry. However, a video barium swallow remains a useful investi- proportion of patients have normal appearing esophagus. Thus,
gation and, in some situations, outperforms gastroscopy. routine mucosal biopsying is recommended in all patients with
Assessment of esophageal motility has advanced substantially dysphagia without an obvious identifiable cause, even if the

Journal of Gastroenterology and Hepatology 27 (2012) 873881 875

2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Evaluation of dysphagia P Kuo et al.

Figure 1 Endoscopic appearance of eosino-

philic esophagitis: (a) furrow (b) rings (c)
luminal narrowing and structuring (arrows),
and (d) a linear ulcerative tear after a food
bolus obstruction.

esophagus appears entirely normal. Esophageal dilatation is thus providing more detailed mapping of esophageal motor func-
an effective therapeutic modality for esophageal web, peptic stric- tion, including the upper and lower esophageal sphincters.5,1315
ture, anastomotic stricture, radiation related stricture or Schatzkis A further advancement in manometry has been the invention of
ring. For patients with achalasia who are not suitable for the topographical (or contour, or color) plot, which has largely
surgical myotomy, endoscopic-guided pneumatic dilatation and replaced the traditional line plot (Fig. 3).16,17 The main advantage
botulinum toxin injection at the LOS are the other therapeutic is more rapid interpretation of results, as it is easier for the human
alternatives. eye to recognize colors rather than lines. The combination of HRM
Gastroscopy can also be useful in providing clues to an under- with topography, termed high-resolution esophageal pressure
lying motility disorder. While the sensitivity and specificity are topography,18 allows more precise measurement of esophageal
relatively low, the presence of a dilated esophagus, a paucity of pressures, and has been shown to have superior diagnostic sensi-
lumen-occluding contractions, and a tight lower esophageal tivity for achalasia compared with limited conventional manom-
sphincter could suggest potential underlying achalasia. Gastros- etry (72% vs 56%).17 However, despite the improved sensitivity
copy should also be considered as part of the assessment of acha- of HRM compared with conventional manometry, convincing
lasia by direct visualization of the gastro-esophageal junction and additional benefit in terms of patient outcome remains to be
gastric cardia in order to detect any underlying carcinoma causing demonstrated.
pseudoachalasia.12 On rare occasions, the only clue for Overall, manometry, whether it be in the conventional or high-
pseudoachalasia related to malignancy outside the GI tract is a lack resolution form, remains the most important tool in assessing
of ability to completely efface the waist of the lower esophageal esophageal motility. It is highly sensitive in detecting pressure
sphincter narrowing on pneumatic dilatation (Fig. 2). changes, correlates reasonably well with bolus transit, and remains
the gold-standard test in diagnosing conditions such as achalasia
and esophageal spasm.
Manometry is the most sensitive and accurate technique to diag-
nose esophageal motility disorders.5,13 While the technique has
been available for over 30 years, recent advances in technology Scintigraphy is an often forgotten and somewhat superseded test
have substantially improved its recording power and fidelity. Stan- for assessing dysphagia. The main role for the radionuclide transit
dard manometry relies on a perfused assembly with 8 or 16 record- test is as a screening test to detect an esophageal transit problem.
ing points. However, high-resolution manometry (HRM) has been It involves the ingestion of a liquid or solid bolus labeled with a
developed with up to 36 recording points. This enables pressure radionuclide such as 99mTc-DTPA, and the radionuclide movement
measurements of 1 cm or less apart along the entire esophagus, recorded by a gamma camera, capable of measuring esophageal

876 Journal of Gastroenterology and Hepatology 27 (2012) 873881

2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
P Kuo et al. Evaluation of dysphagia

Figure 2 A case of progressive dysphagia

due to pseudoachalasia related to lung cancer.
Upper gastrointestinal (GI) endoscope
showed a normal gastro-esophageal junction
(GOJ) with no mucosa lesion (a,b). Barium
swallow outlined a narrowing at the gastro-
esophageal junction (GOJ) (c), in which the
waist of the narrowing at the failed to efface
by a 35 mm pneumatic balloon dilator main-
tained at 18 psi pressure (d, white arrow).
Despite the normal appearing high resolution
computed tomography (CT) scan, endoscopic
ultrasound showed an eccentric wall thicken-
ing and an adjacent mass at the GOJ; EUS
guided fine needle aspiration obtained large
cell carcinoma of lung origin (e).

bolus transit time and clearance.1922 Even though it is reported to boluses also provides a more physiological assessment of motility
have high sensitivity and specificity in detecting esophageal motor than the more conventional liquid boluses used in manometry. In
abnormalities,20 scintigraphy has a number of disadvantages, a multi-centre study on 40 patients with NOD, impedance moni-
including handling of radioactive material and radiation exposure, toring was shown to identify abnormalities of transit in 35% of
poor anatomical definition compared with barium swallow, and a patients with NOD who had apparently normal manometric
lack of well-defined diagnostic criteria. Hence, this technique is assessment.24 Conversely, manometric abnormalities do not
rarely used in clinical practice. always translate to abnormal bolus transit.24,25 Bolus transit was
normal in up to 15% of patients with manometric diagnosis of
ineffective esophageal motility and one third of patients with
Future and emerging techniques for diffuse esophageal spasm.24 Impedance, however, is of limited
esophageal motility assessment use in patients with achalasia, presumably due to esophageal
Multichannel intraluminal impedance More recently, combined impedance-manometry has also been
Until recently, the only method to measure bolus transit in the used to assess oropharyngeal transit and risk of aspiration,27
esophagus was by fluoroscopy or scintigraphy. However, these either as an alternative or adjunct to radiology. Using fluoroscopy
are unsuitable for routine and repeated use due to exposure to as the gold standard, a number of important pressure-flow vari-
ionizing radiation. Impedance monitoring in the esophagus offers ables were identified from the combined impedance-manometry
an alternative method to assess bolus transit without exposure to assessment which, in turn, was used in an automated analytic
radiation. It has been shown to have an accuracy of 97% com- program to evaluate the swallow risk index. This approach has
pared with fluoroscopy.23 Impedance uses the changes in electri- been shown to positively predict pharyngeal dysfunction and risk
cal conductivity associated with the passage of a bolus to map of aspiration.27
bolus transit and clearance (Fig. 4). Recent developments have
enabled the data to be depicted as a topographical plot as with
Functional lumen imaging probe
manometric data.
Impedance monitoring is used in combination with manometry The functional lumen imaging probe is a largely experimental tool
in the evaluation of non-obstructive dysphagia (NOD). The value not yet in routine clinical use. The technique uses impedance
of impedance lies with it being a complementary, rather than planimetry, which measures impedance inside a saline-filled cylin-
competing, tool to manometry by providing information on the drical balloon, thus allowing calculation of the cross-sectional area
functional outcome of motility; namely flow or transit. Thus, of the balloon.8,28,29 This tool has been used to evaluate the opening
impedance allows for inferences to be made about the relationship and pressure across the gastroesophageal junction, and may prove
between abnormalities of motility seen on manometry with abnor- to be useful in assessing patients with achalasia before and after
malities in bolus transit seen on impedance. The use of viscous treatment.8

Journal of Gastroenterology and Hepatology 27 (2012) 873881 877

2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Evaluation of dysphagia P Kuo et al.

Figure 3 High resolution manometry with topographical analysis. Picture shows two 5 mL water swallows with the upper high pressure zone
representing the upper esophageal sphincter, and the lower high pressure zone the lower esophageal sphincter, and esophageal peristalsis in
between. The amplitude of pressure waves detected is converted to colors according to the colour code shown on the left hand side.

More recently, impedance planimetry has been further modified information on the contractions of both longitudinal and circular
to measure the axial (or longitudinal) force in the esophagus, muscles can be obtained.37,38
rather than the cross-sectional area, which offers additional infor- Using high frequency intraluminal ultrasound (HFIUS) in
mation regarding the longitudinal propulsive force exerted on a patients with spastic esophageal disorders including achalasia,
bolus, in addition to horizontal force measured by manometry.30,31 diffuse esophageal spasm, and nutcracker esophagus, the baseline
At present, the clinical use of impedance planimetry is yet to esophageal muscle thickness was found to be greater than in
be established, with the most promising use being for evaluating healthy volunteers.37 Further, this increase in muscle thickness
gastroesophageal junction compliance after treatment for appeared to correlate with the severity of the underlying disease,
achalasia. i.e. greatest in achalasia and least in nutcracker esophagus.36 In
achalasia, swallow-induced longitudinal muscle contraction was
found to be a significant contributor to esophageal emptying by
High frequency intraluminal ultrasound
increasing pan-esophageal pressure to overcome the poorly relax-
Catheter-based high frequency intraluminal ultrasound probes ing lower esophageal sphincter.39 HFIUS appears to be a promis-
range from 13 mm in diameter, and the transducer can provide ing technique in measuring esophageal longitudinal muscle
either linear or cross-sectional images.3235 The ultrasound is able contraction, with its role lying predominantly in physiological
to dynamically assess esophageal longitudinal muscle contrac- studies, especially when used in combination with other tech-
tions, as indicated by an increase in cross-sectional muscle layer niques such as manometry. Operator dependency, and the lack of
thickness.10,35,36 When used in combination with manometry, an automated analysis means its widespread use will be limited.

878 Journal of Gastroenterology and Hepatology 27 (2012) 873881

2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
P Kuo et al. Evaluation of dysphagia

A recommended approach further esophageal assessment must take place, with at least a
gastroscopy (provided the patient is fit for such procedure), to
The first step in the evaluation of dysphagia is to take a careful exclude important causes such as cancer and stricture, as well as
history, with the aim of distinguishing whether the cause is eosinophilic esophagitis; the only exception is when the dysphagia
oropharyngeal or esophageal, and whether it is mechanical or occurs in the context of suspected uncomplicated reflux disease,
dysmotility. If the cause is deemed likely oropharyngeal, then where an initial trial of acid suppressing therapy would be recom-
referral to a neurologist or ENT specialist, with or without speech mended. The threshold to take biopsies from an apparently normal
pathologist involvement, will be appropriate. Unless an esoph- esophagus should be low.
ageal cause can be confidently excluded based on history, then If the patient still suffers from troublesome symptoms despite a
normal gastroscopy (and biopsy), dedicated motility testing is
warranted. The choice of test depends largely upon the perceived
likely diagnosis, patient characteristics and local expertise. An
elderly patient with significant co-morbidities should first undergo
a barium swallow, as it is non-invasive, and the chance of finding
a treatable dysmotility condition is small; further motility testing
should not be performed and symptoms managed conservatively
unless achalasia or esophageal spasm is suspected, in which case
manometry is required to confirm the diagnosis. In a younger
patient, where the probability of a potentially treatable dysmotility
condition is high, manometry should be performed first after gas-
troscopy, ideally with high-resolution manometry with topogra-
phy, given its superior diagnostic sensitivity for achalasia,
compared with conventional manometry. If manometric findings
are unremarkable, then the patient is highly unlikely to have sig-
nificant underlying dysmotility, and subsequent management
should therefore be conservative. (Fig. 5)

Dysphagia is a common problem and evaluation should start with
careful history taking, to guide subsequent diagnostic testing and
Figure 4 Impedance tracing for measuring bolus transit, outlining the management. Gastroscopy is usually the investigation of first
corresponded changes in pressure and impedance traces at different choice to exclude an obstructive lesion. Many techniques are cur-
bolus position in relation to the recording segment. rently available for assessing esophageal motor function, although

Figure 5 A recommended algorithm for the

evaluation of dysphagia. DES, diffuse esoph-
ageal spasm; HR manometry, high resolution

Journal of Gastroenterology and Hepatology 27 (2012) 873881 879

2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Evaluation of dysphagia P Kuo et al.

manometry and barium swallow remain the most clinically useful. 16 Clouse RE, Staiano A. Topography of the esophageal
High-resolution manometry with topography is now the new peristaltic pressure wave. Am. J. Physiol. 1991; 261 (4 Pt 1):
benchmark in assessing esophageal pressures and diagnosing con- G67784.
ditions such as achalasia and esophageal spasm. Combining 17 Clouse RE, Staiano A, Alrakawi A, Haroian L. Application of
topographical methods to clinical esophageal manometry. Am. J.
impedance with manometry in assessing bolus transit currently
Gastroenterol. 2000; 95: 272030.
remains a research tool, as is the functional lumen imaging probe 18 Kahrilas PJ. Esophageal motor disorders in terms of high-resolution
and high frequency intraluminal ultrasound. esophageal pressure topography: what has changed? Am. J.
Gastroenterol. 2010; 105: 9817.
References 19 Holloway RH, Lange RC, Plankey MW, McCallum RW. Detection
of esophageal motor disorders by radionuclide transit studies. A
1 Wilkins T, Gillies RA, Thomas AM, Wagner PJ. The prevalence of reappraisal. Dig. Dis. Sci. 1989; 34: 90512.
dysphagia in primary care patients: a HamesNet Research Network 20 Taillefer R, Jadliwalla M, Pellerin E, Lafontaine E, Duranceau A.
study. J. Am. Board Fam. Med. 2007; 20: 14450. Radionuclide esophageal transit study in detection of esophageal
2 Cook IJ. Oropharyngeal dysphagia. Gastroenterol. Clin. North Am. motor dysfunction: comparison with motility studies (manometry). J.
2009; 38: 41131. Nucl. Med. 1990; 31: 19216.
3 Spieker MR. Evaluating dysphagia. Am. Fam. Physician 2000; 61: 21 Sasso G, Rambaldi P, Sasso FS et al. Scintigraphic evaluation of
363948. esophageal transit during radiotherapy to the mediastinum. BMC
4 Wilcox CM, Alexander LN, Clark WS. Localization of an Gastroenterol. 2008; 8: 5161.
obstructing esophageal lesion. Is the patient accurate? Dig. Dis. Sci. 22 Bestetti A, Carola F, Conciato L, Marasini B, Tarolo GL.
1995; 40: 21926. Esophageal scintigraphy with a semisolid meal to evaluate
5 Pandolfino JE, Fox MR, Bredenoord AJ, Kahrilas PJ. esophageal dysmotility in systemic sclerosis and Raynauds
High-resolution manometry in clinical practice: utilizing pressure phenomenon. J. Nucl. Med. 1999; 40: 7784.
topography to classify esophageal motility abnormalities. 23 Imam H, Shay S, Ali A, Baker M. Bolus transit patterns in healthy
Neurogastroenterol. Motil. 2009; 21: 796806. subjects: a study using simultaneous impedance monitoring,
6 Nguyen NQ, Rigda R, Tippett M, Conchillo J, Smout AJ, videoesophagram, and esophageal manometry. Am. J. Physiol.
Holloway RH. Assessment of esophageal motor function using Gastrointest. Liver Physiol. 2005; 288: G10006.
combined perfusion manometry and multi-channel intra-luminal 24 Conchillo JM, Nguyen NQ, Samsom M, Holloway RH, Smout AJ.
impedance measurement in normal subjects. Neurogastroenterol. Multichannel intraluminal impedance monitoring in the evaluation of
Motil. 2005; 17: 45865. patients with non-obstructive Dysphagia. Am. J. Gastroenterol. 2005;
7 Nguyen NQ, Tippett M, Smout AJ, Holloway RH.Relationship 100: 262432.
between pressure wave amplitude and esophageal bolus clearance 25 Tutuian R, Castell DO. Combined multichannel intraluminal
assessed by combined manometry and multichannel intraluminal impedance and manometry clarifies esophageal function
impedance measurement. Am. J. Gastroenterol. 2006; 101: abnormalities: study in 350 patients. Am. J. Gastroenterol. 2004; 99:
247684. 101119.
8 McMahon BP, Frkjaer JB, Kunwald P, et al. The functional lumen 26 Conchillo JM, Selimah M, Bredenoord AJ, Samsom M, Smout AJ.
imaging probe (FLIP) for evaluation of the esophagogastric junction. Assessment of esophageal emptying in achalasia patients by
Am. J. Physiol. Gastrointest. Liver Physiol. 2007; 292: G37784. intraluminal impedance monitoring. Neurogastroenterol. Motil. 2006;
9 McMahon BP, Frkjaer JB, Liao D, Kunwald P, Drewes AM, 18: 9717.
Gregersen H. A new technique for evaluating sphincter function in 27 Omari TI, Dejaeger E, van Beckevoort D et al. A method to
visceral organs: application of the functional lumen imaging probe objectively assess swallow function in adults with suspected
(FLIP) for the evaluation of the oesophago-gastric junction. Physiol. aspiration. Gastroenterology 2011; 140: 145463.
Meas. 2005; 26: 82336. 28 Gregersen H, Djurhuus JC. Impedance planimetry: a new approach
10 Boesmans W, Vanden Berghe P, Farre R, Sifrim D. Esophageal to biomechanical intestinal wall properties. Dig. Dis. 1991; 9:
shortening: in vivo validation of high-frequency ultrasound 33240.
measurements of esophageal muscle wall thickness. Gut 2010; 59: 29 McMahon BP, Drewes AM, Gregersen H. Functional oesophago-
43340. gastric junction imaging. World J. Gastroenterol. 2006; 12: 281824.
11 Andersson M, Lundell L, Kostic S et al. Evaluation of the response 30 Gravesen FH, Funch-Jensen P, Gregersen H, Drewes AM. Axial
to treatment in patients with idiopathic achalasia by the timed barium force measurement for esophageal function testing. World J.
esophagogram: results from a randomized clinical trial. Dis. Gastroenterol. 2009; 15: 13943.
Esophagus 2009; 22: 26473. 31 Gravesen FH, McMahon BP, Drewes AM, Gregersen H.
12 Liu W, Fackler W, Rice TW, Richter JE, Achkar E, Goldblum JR. Measurement of the axial force during primary peristalsis in the
The pathogenesis of pseudoachalasia: a clinicopathologic study of 13 oesophagus using a novel electrical impedance technology. Physiol.
cases of a rare entity. Am. J. Surg. Pathol. 2002; 26: 7848. Meas. 2008; 29: 38999.
13 Bogte A, Bredenoord AJ, Oors J, Siersema PD, Smout AJ. 32 Liu JB, Miller LS, Goldberg BB. Endoluminal ultrasound in
Reproducibility of esophageal high-resolution manometry. gastroenterology: application of new technology. Clin. Diagn.
Neurogastroenterol. Motil. 2011; 23: e2716. Ultrasound 1994; 29: 185215.
14 Pandolfino JE, Ghosh SK, Zhang Q, Jarosz A, Shah N, Kahrilas PJ. 33 Liu JB, Miller LS, Goldberg BB et al. Transnasal US of the
Quantifying EGJ morphology and relaxation with high-resolution esophagus: preliminary morphologic and function studies. Radiology
manometry: a study of 75 asymptomatic volunteers. Am. J. Physiol. 1992; 184: 7217.
Gastrointest. Liver Physiol. 2006; 290: G103340. 34 Miller LS, Liu JB, Klenn PJ, Dhuria M, Feld RI, Goldberg BB.
15 Pandolfino JE, Kahrilas PJ. New technologies in the gastrointestinal High-frequency endoluminal ultrasonography of the esophagus
clinic and research: impedance and high-resolution manometry. in human autopsy specimens. J. Ultrasound Med. 1993; 12:
World J. Gastroenterol. 2009; 15: 1318. 5636.

880 Journal of Gastroenterology and Hepatology 27 (2012) 873881

2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
P Kuo et al. Evaluation of dysphagia

35 Mittal RK, Liu J, Puckett JL et al. Sensory and motor function of the pressure in patients with esophageal spasm. Am. J. Physiol.
esophagus: lessons from ultrasound imaging. Gastroenterology 2005; Gastrointest. Liver Physiol. 2002; 282: G101623.
128: 48797. 38 Pehlivanov N, Liu J, Mittal RK. Sustained esophageal contraction: a
36 Mittal RK, Kassab G, Puckett JL, Liu J et al. Hypertrophy of the motor correlate of heartburn symptom. Am. J. Physiol. Gastrointest.
muscularis propria of the lower esophageal sphincter and the body of Liver Physiol. 2001; 281: G74351.
the esophagus in patients with primary motility disorders of the 39 Hong SJ, Bhargava V, Jiang Y, DenBoer D, Mittal RK. A unique
esophagus. Am. J. Gastroenterol. 2003; 98: 170512. esophageal motor pattern that involves longitudinal muscles is
37 Pehlivanov N, Liu J, Kassab GS, Beaumont C, Mittal RK. responsible for emptying in achalasia esophagus. Gastroenterology
Relationship between esophageal muscle thickness and intraluminal 2010; 139: 10211.

Journal of Gastroenterology and Hepatology 27 (2012) 873881 881

2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd