On initial presentation, esophageal dysphagia should be approached methodically with critical attention to patient-provided history. Mechanical or obstructive esophageal disorders are the most common causes of esophageal dysphagia, and patients generally present with dysphagia to solids alone with potential progression to include liquids. In contrast, patient-reported symptoms of dysphagia with both solids and liquids most likely point to an underlying motility disorder. Patients will often present with a history of difficulty swallowing solids.
In some clinical scenarios, symptoms may manifest with food bolus impaction. In younger patients with non-progressive dysphagia, eosinophilic esophagitis EoE should be considered. The exact etiology of EoE remains unknown, but it is thought to be related to esophageal reflux or atopy.
EoE is diagnosed based on characteristic endoscopic findings and histologic evidence of mucosal eosinophilia. Figure 2. However, several patients can present with a grossly normal-appearing esophagus, therefore, it is important to maintain a high level of suspicion regardless of endoscopic findings. Alternatively, esophageal webs and Schatzki rings can cause non-progressive dysphagia that can occur across all age groups. A Schatzki ring is a thin mucosal structure often found near the gastroesophageal junction.
Photomicrograph of an esophageal biopsy obtained during routine upper endoscopy shows squamous mucosa with increased intraepithelial eosinophils, basal hyperplasia, and elongation of papillae. In contrast to intermittent or non-progressive dysphagia, progressive solid food dysphagia is worrisome for an esophageal stricture or carcinoma within the esophageal lumen. Peptic strictures are benign esophageal strictures that develop in patients with long-standing GERD and may present similarly to esophageal carcinoma.
Weight loss is not common in patients with peptic strictures, as they often will modify their diet to more tolerable formulations. In patients with rapidly progressive dysphagia, weight loss, and anorexia, esophageal squamous cell carcinoma or adenocarcinoma should be considered until proven otherwise.
Esophageal adenocarcinoma is a growing health concern that is expected to increase in incidence over the next 10 years. Esophageal adenocarcinoma can occur anywhere in the esophageal lumen or at the gastric cardia. Gastric cardia lesions can also present with progressive dysphagia or give an achalasia like picture called pseudoachalasia. Based on location, the esophagus is subject to external compression by surrounding structures within the mediastinum. They may lead to hemodynamic compromise and luminal narrowing.
Dysphagia lusoria is a term that refers to any congenital vascular abnormality leading to esophageal compression and the development of intermittent or persistent dysphagia symptoms. Anatomically, dysphagia lusoria typically refers to an aberrant right subclavian artery arising from the left side of the aortic arch, a double aortic arch, or a right aortic arch with left ligamentum arteriosum. Rarely, any clinical entity contributing to left atrial enlargement can lead to esophageal compression based on anatomic positioning.
Clinical clues suggestive of extrinsic compression from vascular or cardiac etiologies include respiratory distress, hypotension, and atypical chest pain. A report of dysphagia to liquids or a combination of solids and liquids should prompt concern for an abnormality in esophageal motility. The major motility disorders are broken down into achalasia, diffuse esophageal spasm, hypertensive esophagus, and ineffective esophageal motility.
This disease occurs as a result of degeneration of myenteric plexus ganglion cells, which leads to an imbalance between excitatory and inhibitory neurons with resulting sustained lower esophageal sphincter contraction.
The trigger for this overall process, however, often remains unclear with the exception of Chagas disease. Patients with a hypercontractile esophagus may also present with chest pain due to elevated esophageal and lower sphincter pressures. At the other end of the spectrum, motility tracings that demonstrate low amplitude pressures or failed peristalsis are considered ineffective esophageal motility. The first line of diagnostic evaluation is centered around obtaining a detailed clinical history and physical exam Figure 1.
Evaluation of the oropharynx, neck and dentition may provide helpful clues. The main diagnostic tests to evaluate dysphagia include modified barium swallow, barium esophagram, endoscopy, and manometry. Barium esophagraphy is often utilized as the initial diagnostic test if there are clinical features that raise concern for complications related to blind endoscopic intubation. If symptoms persist despite normal endoscopic and manometric evaluation, radiographic evaluation with ingestion of barium-coated foods or tablets can help identify subtle luminal narrowing or functional dysphagia.
Endoscopy offers the dual benefits of providing both diagnostic information and a route of therapeutic intervention. It is especially valuable when symptoms are suggestive of an anatomic abnormality and if there is concern for a malignant or premalignant condition.
This twofold application has also demonstrated a significant cost benefit when used as the initial diagnostic tool as barium swallow generally prompts follow-up testing or intervention.
Manometry is employed if dysmotility is suspected, as it provides insight into esophageal peristalsis and sphincter function Figure 3.
Manometry helps differentiate between subsets of motility disorders and can help predict response to endoscopic and surgical interventions. High resolution manometry images demonstrate the pressures along the length of the esophagus vertical axis over time horizonal axis after swallows in the setting of common abnormalities.
Normal esophageal manometry with normal progression of the pressure wave over time; B. Manometry in achalasia type II classic achalasia shows a lack of a normal peristaltic pressure wave; C. Manometry demonstrating esophagogastric junction outflow obstruction EGJOO due to abnormally high pressures. Management of esophageal dysphagia is targeted to treat the underlying etiology.
Mechanical obstruction due to intraluminal rings, webs, and benign strictures can be endoscopically dilated using a mechanical or balloon dilation. Bougie dilator is considered to be more effective and associated with less risks, as it provides both radial and axial forces and decreases the degree of force applied within the lumen. Balloon dilators, on the other hand, exert an isolated radial force, which allows for less dilation pressure but can be associated with higher perforation risk.
Concurrent acid suppression therapy is frequently recommended with dilation to reduce stricture recurrence after successful dilation. Esophageal stents and intralesional steroids may be considered in refractory cases of benign strictures to help maintain lumen patency but are usually reserved for malignant strictures. Obstruction secondary to intraluminal masses, diverticula, and extrinsic compression may require surgical intervention.
Dysphagia due to abnormal motility requires therapeutic approaches that target esophageal kinetics and pressure. Achalasia therapy focuses on reduction of the pressure created by the lower esophageal sphincter. The most effective nonsurgical intervention to date has been pneumatic dilation, which involves balloon dilation across the lower sphincter in an attempt to tear the muscle fibers in a controlled manner. Functional dysphagia management can be challenging and involves elimination of motility-altering medications, a trial of high dose acid suppression, consideration for empiric bougie dilation, trials of neuromodulatory medications, and reassurance with simple lifestyle measures.
An initial description of dysphagia offers an expansive list of potential etiologies, however, an organized approach to evaluation by means of thorough clinical history and use of modern diagnostic techniques can help determine underlying pathology and direct therapeutic options in a targeted manner. Louis, Mo. Contact: ude.
National Center for Biotechnology Information , U. Journal List Mo Med v. Mo Med. Author information Copyright and License information Disclaimer. Corresponding author. Copyright by the Missouri State Medical Association. This article has been cited by other articles in PMC. Abstract A complaint of dysphagia suggests difficulty in swallowing and is characterized based on the symptoms and location of pathology.
Introduction Dysphagia is defined as an abnormal delay in the movement of a food bolus from the oropharynx to the stomach. Epidemiology Few population-based studies are available on the prevalence of dysphagia in the community. Does it take longer than one second to pass food from the mouth to the esophagus?
What type of food or liquids cause symptoms? Are symptoms intermittent or progressive? Is there heartburn? Open in a separate window. Figure 1. Oropharyngeal Dysphagia The oropharyngeal phase of swallowing involves transferring a food bolus posteriorly to the epiglottis and then to the upper esophageal sphincter. Esophageal Dysphagia Esophageal dysphagia can occur due to structural abnormalities or dysmotility.
Intermittent Non-Progressive Dysphagia Patients will often present with a history of difficulty swallowing solids. Progressive Dysphagia In contrast to intermittent or non-progressive dysphagia, progressive solid food dysphagia is worrisome for an esophageal stricture or carcinoma within the esophageal lumen. Extrinsic Dysphagia Based on location, the esophagus is subject to external compression by surrounding structures within the mediastinum. Dysmotility A report of dysphagia to liquids or a combination of solids and liquids should prompt concern for an abnormality in esophageal motility.
Figure 3. Therapeutics Management of esophageal dysphagia is targeted to treat the underlying etiology. The SAFE provides clinicians with a carefully standardized, efficient, and comprehensive way to evaluate swallowing. This test is based on the findings of the latest research in swallowing disorders and the practical needs of therapists conducting such assessments. It is designed to assist in providing a definitive diagnosis or label of dysphagia. For the third edition, the authors have added a companion workbook that includes practical exercises accompanying each chapterfor example, a step-by-step tutorial for making objective measures of timing and displacement from fluoroscopic swallow studies.
The exercises are designed to clarify and expand on information presented in the text and should be of interest not only to students but to practicing clinicians hoping to add new skills to their repertoires.
In addition, it includes both normal and patient fluoroscopy studies for review and measurement. The patient studies selected are representative of impairments typically observed in clinical practice inpatient and outpatient. Other media clips illustrate each instrumental assessment technique introduced in the book e.
This product is delivered by one of our digital delivery partners. Use this link to purchase now. This best-selling book is a practical resource that gives you an evidence-based working knowledge of the evaluation and treatment of dysphagia plus tools to organize your dysphagia services. The fourth edition provides current information about evaluation and treatment, with particular attention to updating evidence for treatment techniques.
Most chapters contain significant revisions, such as the following:. Shopping Cart 0 Advanced Search. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising.
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Log In Join Us. As noted, a separate workbook is also available to reinforce student learning of the concepts presented in the textbook and DVD. As healthcare reimbursements get tighter, the days of trialing techniques for weeks, changing techniques, and trialing again are over — we need to choose the best options for our patients right from the start. So how can we develop an appropriate treatment plan for each patient? The first step is to know and understand the anatomy and physiology of the normal swallow.
Take the time to educate yourself on what a healthy swallow of a young person looks like and how it changes as people age normally. But the simple presence of piecemeal deglutition is not abnormal.
We also need to know the anatomy and physiology so that we can understand how changing it, whether through exercises or strategies, can impede or remediate the swallow.
Published September 7, by Plural Publishing Inc. Written in English. How to cite this article: Lalsa S P. Your doctor will likely perform a physical examination and may use a variety of tests to determine the cause of your swallowing problem.
SAFE: Swallowing Ability and Function Evaluation Otolaryngology and speech therapy evaluation in the assessment of oropharyngeal dysphagia: a combined protocol proposal. The exam was performed in 1, patients from May to December There were See larger image.
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