Dysphagia

Matei Caleap

Background

  • Oropharyngeal dysphagia - difficulty initiating swallow, experiencing coughing, choking; usually sensation present in 1st second of initiating swallow. 
  • Esophageal dysphagia - difficulty swallowing several seconds after initiation.

Presentation

  • Solids only = mechanical.
  • Progressive symptoms: esophageal stricture, peptic stricture, or esophageal cancer.
  • Not progressive symptoms: eosinophilic esophagitis (intermittent, “food-impaction sensation”), esophageal rings or web, external compression (vascular abnormalities).
  • Solids and Liquids = motility disorder.
  • Progressive symptoms: achalasia or systemic sclerosis.
  • Not progressive symptoms: esophageal hypercontractility or esophageal outflow obstruction.
  • Red flags: Progressive dysphagia, weight loss, age >50 years, and alarm symptoms warrant urgent endoscopy to exclude malignancy.

Evaluation: Esophageal Dysphagia

  • Normal upper endoscopy: 
    • Barium swallow for dysphagia to solids only if mechanical obstruction still suspected 
    • Esophageal manometry for dysphagia to solids and liquids or suspecting motility disorder. Helps assess intraluminal pressures, peristalsis, and bolus transit 
    • Barium swallow if history of prior radiation, caustic injury, surgery, suspicion for proximal esophageal lesion (Zenker’s) or complex stricture or EGJ outflow obstruction (EGJOO) 
    • Do not order if food impaction suspected or imminent endoscopy  
    • Order as timed barium esophagram. If barium emptying is normal and tablet passes without issues, it makes motility abnormality or stricture less likely. 
  • Chicago Classification v4: 
    • Disorders of EGJ outflow: Achalasia (types I, II, III) and EGJOO 
    • Disorder of Peristalsis: Absent contractility, distal esophageal spasm, hypercontractile esophagus, ineffective esophageal motility

Evaluation: Oropharyngeal Dysphagia

  • Referral to speech-language pathology for video fluoroscopic swallow study (modified barium swallow) or fiberoptic endoscopic evaluation of swallowing (FEES).

Management

  • Food impaction: Endoscopy is the intervention of choice and should not be delayed by pharmacologic attempts. Glucagon may be considered in select cases (distal impactions, facilities without immediate endoscopy access) but should not delay definitive management. 
  • Achalasia: 
    • For types I and II achalasia, pneumatic dilation (PD), laparoscopic Heller myotomy (LHM) with partial fundoplication, and peroral endoscopic myotomy (POEM) are all effective first-line options. 
    • For type III achalasia, POEM or tailored LHM is preferred due to superior outcomes with longer myotomy. 
    • EGJOO: medical therapy with CCBs or nitrates or acotiamide; POEM in bad cases 
  • Distal Esophageal Spasm and Hypercontractile Esophagus: 
    • Treatment is primarily conservative with lifestyle modifications, dietary changes, and reassurance. 
    • Smooth muscle relaxants (CCBs, nitrates, PDE-5 inhibitors) may provide symptomatic relief. POEM an option in bad/refractory cases.
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