Dysphagia
Julie Anne Giannini
Background
- Oropharyngeal dysphagia- difficulty initiating swallow, experiencing coughing, choking
- Esophageal dysphagia- difficulty swallowing several seconds after initiation
Presentation
- Difficulty swallowing solids, liquids, or both?
- Solids only = mechanical
- Progressive symptoms: esophageal stricture, peptic stricture, or esophageal cancer
- Not progressive symptoms: eosinophilic esophagitis, 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
Evaluation: Esophageal Dysphagia
- Upper endoscopy +/- biopsy if no previous history of esophageal abnormalities
- 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
- Barium swallow if history of prior radiation, caustic injury, surgery, suspicion for proximal esophageal lesion (Zenker’s) or complex stricture
- 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 rules out motility abnormality or stricture.
- Esophageal manometry helps assess intraluminal pressures, peristalsis, and bolus transit.
- Disorders of EGJ outflow: achalasia, EGJ outflow obstruction
- Disorder of Peristalsis: absent contractility, distal esophageal spasm, hypercontractile esophagus, ineffective esophageal motility
Evaluation: Oropharyngeal Dysphagia
- Videofluoroscopic modified barium swallow and fiberoptic endoscopic evaluation of swallowing (FEES)
