Approach to a patient with Dysphagia

Dr. Sayeed Ahmed
Assistant Registrar Department of Gastroenterology RMCH

Introduction

Dysphagia is defined as a sensation of "sticking" or obstruction of the passage of food through the mouth, pharynx, or esophagus. However, it is often used as an umbrella term to include other symptoms related to swallowing difficulty.

no difficulty is encountered when swallowing is performed. Phagophobia means fear of swallowing. . However. Globus pharyngeus is the sensation of a lump lodged in the throat.Aphagia signifies complete esophageal obstruction. which is usually due to bolus impaction and represents a medical emergency. Odynophagia means painful swallowing.

Patients complain of difficulty initiating swallowing. . It results from abnormal function proximal to the esophagus. and tracheal aspiration followed by coughing.Oropharyngeal dysphagia Oropharyngeal dysphagia is difficulty emptying material from the oropharynx into the esophagus. nasal regurgitation.

progressive bulbar palsy. pseudobulbar palsy) ± Bulbar poliomyelitis ‡ Muscular ± Myasthenia gravis ± Dermatomyositis ± Muscular dystrophy .Aetiology ‡ Neurologic ± Stroke ± Parkinson's disease ± Multiple sclerosis ± Some motor neuron disorders (amyotrophic lateral sclerosis.

It results from either a motility disorder or a mechanical obstruction .Esophageal dysphagia Esophageal dysphagia is difficulty passing food down the esophagus.

Aetilogy ‡ Motility disorder ± ± ± ± ± ± ± ± Achalasia Diffuse esophageal spasm Systemic sclerosis Eosinophilic esophagitis ‡ Mechanical obstruction Peptic stricture Esophageal cancer Lower esophageal rings Extrinsic compression (eg. aortic aneurysm. aberrant subclavian artery. substernal thyroid. from enlarged Lt atrium. and thoracic tumor) ± Caustic ingestion ± Candidiasis .

or both.Complications Dysphagia can lead to tracheal aspiration of ingested material. Prolonged dysphagia often leads to inadequate nutrition and weight loss. recurrent aspiration may eventually lead to chronic lung disease. . oral secretions. Aspiration can cause acute pneumonia.

and connective tissue disorders and on the presence of complications. ‡ Associated symptoms provide important diagnostic clues. .History ‡ The history can provide a presumptive diagnosis in >80% of patients. ‡ Review of symptoms should focus on symptoms suggestive of neuromuscular. GI.

thickening). ‡ Symptoms of connective tissue disorders include muscle and joint pain. and difficulty speaking. and skin changes (eg. ‡ Important GI symptoms include heartburn or other chest discomfort suggestive of reflux. rash. gait or balance disturbance.‡ Important neuromuscular symptoms include weakness and easy fatigability. Raynaud's phenomenon. swelling. tremor. .

. ‡ Tracheobronchial aspiration unrelated to swallowing may be due to achalasia or gastroesophageal reflux.‡ Nasal regurgitation and tracheobronchial aspiration with swallowing are hallmarks of pharyngeal paralysis or a tracheoesophageal fistula.

the primary lesion is usually in the larynx.‡ Association of laryngeal symptoms and dysphagia occurs in various neuromuscular disorders. Sometimes hoarseness may be due to laryngitis secondary to gastroesophageal reflux. ‡ When hoarseness precedes dysphagia. The presence of hoarseness may be an important diagnostic clue. hoarseness following dysphagia may suggest involvement of the recurrent laryngeal nerve by extension of esophageal carcinoma. .

‡ Unilateral wheezing with dysphagia may indicate a mediastinal mass involving the esophagus and a large bronchus. .‡ Hiccups may rarely occur with a lesion in the distal portion of the esophagus.

‡ In contrast.‡ The type of food causing dysphagia provides useful information. . ‡ Patients with scleroderma have dysphagia to solids that is unrelated to posture and to liquids while recumbent but not upright. motor dysphagia due to achalasia and DES is equally affected by solids and liquids from the very onset. In advanced obstruction. dysphagia occurs with liquids as well as solids. ‡ Difficulty only with solids implies mechanical dysphagia with a lumen that is not severely narrowed.

‡ Progressive dysphagia lasting a few weeks to a few months is suggestive of carcinoma of the esophagus.‡ The duration and course of dysphagia are helpful in diagnosis. ‡ Transient dysphagia may be due to an inflammatory process. . ‡ Episodic dysphagia to solids lasting several years indicates a benign disease characteristic of a lower esophageal ring.

‡ Severe weight loss that is out of proportion to the degree of dysphagia is highly suggestive of carcinoma. ‡ Chest pain with dysphagia occurs in DES and related motor disorders. . Chest pain resembling DES may occur in esophageal obstruction due to a large bolus.

‡ A prolonged history of heartburn and reflux preceding dysphagia indicates peptic stricture. previous radiation therapy. ingestion of pills without water. ingestion of caustic agents. . or associated mucocutaneous diseases may provide the cause of esophageal stricture. A history of prolonged nasogastric intubation.

herpes simplex virus. or cytomegalovirus and to tumors such as Kaposi's sarcoma and lymphoma should be considered. herpes. or pill-induced esophagitis should be suspected. .‡ If odynophagia is present. ‡ In patients with AIDS or other immunocompromised states. esophagitis due to opportunistic infections such as Candida. candidal.

with attention to any resting tremor. .hysical examinations ‡ Examination focuses on findings suggestive of neuromuscular. and connective tissue disorders and on the presence of complications. GI. ‡ A complete neurologic examination is essential. the cranial nerves and muscle strength. ‡ General examination should evaluate nutritional status (including body weight).

including dysarthria. ptosis.‡ Signs of bulbar or pseudobulbar palsy. A careful inspection of the mouth and pharynx should disclose lesions that may interfere with passage of food. dysphonia. . and hyperactive jaw jerk. ‡ The neck should be examined for thyromegaly or a spinal abnormality. should be sought. in addition to evidence of generalized neuromuscular disease. tongue atrophy.

‡ Changes in the skin and extremities may suggest a diagnosis of scleroderma and other collagen vascular diseases or mucocutaneous diseases such as pemphigoid or epidermolysis bullosa. which may involve the esophagus. ‡ Pulmonary complications such as acute or chronic aspiration pneumonia may be present. . ‡ Cancer spread to lymph nodes and liver may be evident.

inability to swallow anything) ‡ Dysphagia resulting in weight loss ‡ New focal neurologic deficit.Red flags: Any dysphagia is of concern. drooling. but certain findings are more urgent: ‡ Symptoms of complete obstruction (eg. particularly any objective weakness .

wasting. particularly of facial muscles Muscle fasciculation. probably cancer Peptic stricture . balance disturbance Myasthenia gravis Focal easy fatigability. ataxia. constant dysphagia. myopathy Esophageal obstruction. no neurologic findings GI reflux symptoms Motor neuron disease. weakness Rapidly progressive.Some Helpful Findings in Dysphagia Finding Possible Cause Parkinson's disease Tremor.

erythematous rash. muscle tenderness Raynaud's phenomenon. arthralgias. dyspnea. lung congestions Dermatomyositis Systemic sclerosis Pulmonary aspiration .Intermittent dysphagia Lower esophageal ring or diffuse esophageal spasm Slow progression (months to Achalasia years) of dysphagia to solids and liquids. thyromegaly Extrinsic compression Dusky. sometimes with nocturnal regurgitation Neck mass. skin tightening/ contractures of fingers Cough.

VFSS (videofluroscopic swallowing assessment) by both a radiologist and a swallow therapist is the procedure of choice. Videoendoscopy is currently performed only in specialized centers. Otolaryngoscopic and neurologic evaluation are also usually required. ‡ If oral or pharyngeal dysphagia is suspected. .Diagnostic Procedures ‡ Dysphagia is usually a symptom of organic disease rather than a functional complaint.

barium swallow. esophageal manometry. . In some cases. and impedance testing are useful diagnostic tests. CT examination and endoscopic ultrasound may be useful. esophageal pH.‡ If esophageal mechanical dysphagia is suspected on clinical history. barium swallow and esophagogastroscopy with or without mucosal biopsies are the diagnostic procedures of choice. ‡ For motor esophageal dysphagia. Esophagogastroscopy is also often performed in patients with motor dysphagia to exclude an associated structural abnormality.

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