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Dysphagia
Anthony Lembo, MD, and Filippo Cremonini, MD
Case Scenario
A 52-year-old gentleman comes to your office with a history • Would you classify his dysphagia as esophageal or
of intermittent difficulty swallowing solid food. His symp- oropharyngeal?
toms have been present for the past 5 years. He points to his • What symptoms help determine whether his
supraclavicular notch when describing where the food feels dysphagia is due to a mechanical or motor (ie,
stuck, although he is able to chew his food and transfer it into motility) abnormality?
his posterior pharynx without difficulty. He does not choke
• How can you use the patient’s history to
or cough while eating. Drinking water will usually relieve
distinguish between a benign and malignant cause
his symptoms, although on several occasions he has self-
of his dysphagia?
induced vomiting. His symptoms are slightly worse now than
they were several years ago, which prompted today’s visit.
KEY TERMS
Esophageal dysphagia Difficulty in passage of a bolus from the upper esophagus to the stomach.
Globus Sensation of lump or tightness in the throat unrelated to swallowing.
Mechanical disorder Obstruction of the esophageal lumen.
Motor disorder of the esophagus Dyscoordination of the esophageal contractions.
Odynophagia Pain with swallowing.
Oropharyngeal dysphagia Difficulty initiating the swallowing process (ie, passage of a bolus from the
mouth to the proximal esophagus).
353
354 Section VII Gastrointestinal System
ETIOLOGY the esophagus (eg, ring, web, stricture, cancer), 32% had dys-
phagia related to disturbed esophageal motility (eg, spasm,
The exact prevalence of dysphagia is unknown. Current stud- scleroderma, achalasia), and 21% had no demonstrable struc-
ies estimate the prevalence of dysphagia to be between 16% tural or motor abnormalities in the esophagus or oropharynx.
and 22% among individuals over 50 years of age.3 The esti- Older age, male sex, the presence of weight loss, heartburn,
mated prevalence of dysphagia in younger people is lower. For and a history of prior esophageal dilation significantly pre-
example, in a population survey of persons age 30 to 64 years dicted mechanical causes of dysphagia.8
living in the Midwest, the prevalence of dysphagia was 6% to Eosinophilic esophagitis (EE) is increasing recognized
9%.4 Up to 25% of hospitalized patients and 33% of nursing as a cause of dysphagia in the pediatric as well as the adult
home residents experience dysphagia.5 Most nursing home population. EE can result in narrowing and stricturing of the
residents with dysphagia have oropharyngeal dysphagia.6 esophagus and is a common cause for food impaction, espe-
Oropharyngeal dysphagia complicates up to 67% of strokes cially in young adults. EE is diagnosed by the presence of 15
and places these patients at increased risk for aspiration pneu- eosinophils per high-power field on light microscopy. Recent
monia. The 12-month mortality rate in these persons is as high data suggest that dilatation of the esophagus in patients with
as 45%.7 EE is associated with increased rate of esophageal perfora-
A study at the Mayo Clinic showed that of 499 patients tion. The treatment is avoidance of dietary allergens, topical
with esophageal dysphagia, 47% had an obstructive lesion in steroids, and anti–interleukin-5 antibody if necessary.
Differential Diagnosis
Oropharyngeal dysphagia Examples
Neuromuscular causes Stroke
Cerebral palsy
Multiple sclerosis
Myasthenia gravis
Amyotrophic lateral sclerosis
Parkinson’s disease
Myopathies
Polymyositis/dermatomyositis
Structural causes Zenker diverticulum
Head and neck tumors
Cervical spondylosis
Vertebral osteophytes
Pharyngeal webs (Plummer-Vinson syndrome)
Iatrogenic causes Radiation therapy
Corrosive pill injury
Anticholinergic medications (dries mucous membranes)
Esophageal dysphagia Examples
Motor disorders Achalasia
Diffuse esophageal spasm
Nutcracker esophagus
Chapter 35 Dysphagia 355
Scleroderma
Sjögren syndrome
Chagas disease
Mechanical, intrinsic Tumors (esophageal carcinoma, lymphoma)
Strictures
Lower esophageal rings (Schatzki ring)
Esophageal webs and rings
Eosinophilic (allergic) esophagitis (EE)
Foreign bodies
Mechanical, extrinsic Right-sided aorta
Left atrial enlargement
Aberrant vessels
Mediastinal lymphadenopathy
Substernal thyroid
Iatrogenic Pill esophagitis (doxycycline, nonsteroidal anti-inflammatory drugs
[NSAIDs], alendronate, potassium chloride tablets)
Infectious Candidal esophagitis
Herpes esophagitis
Cytomegalovirus (CMV) esophagitis
Questions Remember
Tell me what happens when you swallow. Avoid interrupting.
When did you first notice that you were having difficulty Do not ask focused questions until the patient is
swallowing? Are your symptoms getting worse? done describing his or her symptoms in detail.
Describe what happens when you try to eat solid foods. Ask the patient to describe these events in detail.
Describe what happens when you drink liquids.
356 Section VII Gastrointestinal System
INTERVIEW FRAMEWORK • Assess for additional alarm symptoms (ie, weight loss,
bleeding, fevers, hematemesis, advanced age).
• Evaluate the patient’s medication list before the • Establish characteristic features of the dysphagia such
interview and consider the potential contribution of the as onset, duration, frequency, location, and precipitat-
medications in dysphagia. ing or alleviating factors. If a patient has not offered this
• Determine whether the patient has symptoms with information with your open-ended questioning, be sure
ingestion of solids only or both liquids and solids to dis- to ask directed questions.
tinguish between mechanical obstruction and neuromus-
cular disorders.
• Determine whether symptoms are progressive or IDENTIFYING ALARM SYMPTOMS
intermittent.
• Older patients presenting with progressive dysphagia,
• Determine whether the patient has any associated symp- particularly those with a past history of alcohol abuse,
toms or comorbid conditions, such as history of stroke, smoking, obesity, or gastroesophageal reflux, should
neurologic disorders, tobacco use, or history of reflux raise concern about an underlying oropharyngeal or
disease. esophageal malignancy.
Serious Diagnoses
Diagnosis Remarks Prevalence
Oropharyngeal Associated with tobacco and chronic alcohol use. 82% of all patients with
or laryngeal oropharyngeal or laryngeal
carcinoma carcinoma experience dysphagia.9
Stroke Most common cause of oropharyngeal dysphagia. 45% of all stroke patients experience
Onset is often abrupt. dysphagia at 3 months.
Head injury
Parkinson’s disease Common cause of oropharyngeal dysphagia. 81% of patients with Parkinson’s
disease have mild dysphagia.
Multiple sclerosis 24%–34% of patients with multiple
sclerosis have permanent
dysphagia.10
FOCUSED QUESTIONS
After hearing the story in the patient’s own words and consid-
ering possible alarm symptoms, ask the following questions to
narrow the differential diagnosis.
Q uestions T H I N K A B O U T. . .
Do you cough, choke, or sense food coming back through Oropharyngeal dysphagia
your nose after swallowing?
Does it feel as if food is getting stuck within the first few Oropharyngeal dysphagia
seconds of swallowing?
Do you have difficulty swallowing liquids, solids, or both? Liquids and solids = motor disorder
Solids progressing to include liquids =
mechanical obstruction
Are your symptoms getting worse? Rapidly progressive symptoms are worrisome
for malignancy
Do you always have trouble swallowing, or are your Intermittent, nonprogressive symptoms suggest a
symptoms intermittent? distal esophageal web or ring
Have you received radiation therapy in the past? Radiation esophagitis
Do you take your medications with fluids? Pill esophagitis. Most commonly associated
with ingestion of iron supplements, aspirin,
Do you take your medications immediately before going to bed?
potassium, doxycycline, and alendronate.
Do you have a medical condition that suppresses your Candidal, herpes simplex virus (HSV), or CMV
immune system (eg, human immunodeficiency virus [HIV], esophagitis
chronic steroid use, chemotherapy)?
—Continued next page
358 Section VII Gastrointestinal System
Continued—
Quality
Is food sticking or getting stuck after you swallow? Esophageal dysphagia
Have you experienced nasal regurgitation? Oropharyngeal dysphagia
Do you have difficulty initiating a swallow? Oropharyngeal dysphagia
Do you choke or cough when you try to swallow? Oropharyngeal dysphagia
Have your symptoms remained the same over a long period Nonprogressive symptoms indicate benign
of time, or are they getting worse? structural lesions such as Schatzki ring or web
Location
Where exactly does the food stick or hang up? Oropharyngeal dysphagia: Patients frequently
point to their cervical region
Esophageal dysphagia: The lesion is at or below
the region to which they point
Time course and frequency
Are your symptoms episodic? Episodic dysphagia to solids over a long period
of time suggests a benign disease such as a lower
esophageal ring
How long have you had these symptoms? Dysphagia of short duration suggests an
inflammatory process
Associated symptoms
Do you hear a gurgling noise when you swallow? Zenker diverticulum
Do you feel like you have bad breath? Halitosis is associated with Zenker diverticulum
Do you regurgitate old foods? Distal esophageal obstruction
Zenker diverticulum
Achalasia
Is it painful to swallow? Esophageal mucosal inflammation (ie,
esophagitis)
Do you experience chest pain? Motor disorders of the esophagus (ie, diffuse
esophageal spasm, achalasia, and scleroderma)
Do you ever have to bear down or raise your arms over your Motor disorders
head to help a food bolus pass?
Are your symptoms worse with very hot or cold liquids? Motor disorders
Do you have a long-standing history of heartburn? Peptic stricture
Are your symptoms relieved by repeated swallows? Motor disorders
Have you ever experienced the sudden onset of dysphagia Esophageal ring
after swallowing pieces of meat?
“Steak house syndrome” (Recurrent episodes of
obstruction in distal esophagus often after eating
a piece of steak or bread. The obstruction is the
result of a lower esophageal ring and is usually
relieved by drinking large amounts of water.)
Chapter 35 Dysphagia 359
Are your symptoms worse when you swallow cold foods? Motor disorders
Dysphagia
Difficulty initiating
Food stops or
swallow (symptoms include
“sticks” after
choking, coughing, nasal
swallowing
regurgitation)
Mechanical Neuromuscular
obstruction disorder
Lower Diffuse
Peptic
esophageal Carcinoma esophageal Scleroderma Achalasia
stricture
ring spasm
• Dysphagia to solid food is most often due to a mechani- • If a food gets stuck and only regurgitation will relieve
cal obstruction, whereas dysphagia to solid and liquid the symptom, the patient probably has a mechanical ob-
food is often due to a motor (motility) disorder. struction. However, if certain physical maneuvers assist
• Dysphagia can occur from impingement of the esopha- the passage of food, then the patient likely has a motility
gus by a vascular anomaly (dysphagia lusoria) such as disorder.
an aberrant right subclavian artery.
• A history of dry mouth or eyes may indicate in-
adequate salivary production. In such cases, it is
PROGNOSIS
particularly important to obtain a detailed review of The prognosis in patients with dysphagia varies from excel-
medications. Anticholinergics, antihistamines, and lent to poor depending on its cause and severity. In patients
certain antihypertensives can reduce salivary flow. with benign mechanical causes for esophageal dysphagia, the
Consider Sjögren syndrome when these sicca symp- prognosis is generally excellent. In contrast, the prognosis of
toms are present. malignant causes for dysphagia is generally poor.
References
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2. Spieker M. Evaluating dysphagia. Am Fam Physician. 12-month outcomes of nursing home patients with aspiration
2000;61:3639–3648. on videofluoroscopy. Dysphagia. 1994;9:141–146.
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Suggested Reading
Fauci AS, Braunwald E, Kasper DL, et al., eds. Dysphagia. In: Richter J. Dysphagia, odynophagia, heartburn and other esophageal
Harrison’s Principles of Internal Medicine. 19th ed. New York, symptoms. In: Sleisenger’s and Fordtram’s Gastrointestinal and
NY: McGraw-Hill Medical, 2008. Liver Disease. New York, NY: Elsevier, 2002.
Goyal & Shaker GI Motility Online. Available at: http://www.
nature.com/gimo.