CHAPTER 1
Approach to dysphagia

John S. A. Collins

Northern Ireland Medical and Dental Training Agency, Royal Victoria Hospital, Belfast, UK

Definitions

Dysphagia refers to a subjective sensation of the obstruction of swallowed solids or liquids from mouth to stomach. Patients most frequently complain that food "sticks" in the retrosternal area or simply will "not go down." Patients may complain of a feeling of choking and chest discomfort. In some cases food material is rapidly regurgitated to relieve symptoms.

Dysphagia can be divided into two types:

• oropharyngeal dysphagia, where there is an inability to initiate the swallowing process and may involve disorders of striated muscle. There may be a sensation of solids or liquids left in the pharynx.
• esophageal dysphagia, which involves disorders of the smooth muscle of the esophagus and results in symptoms within seconds of the Initiation of swallowing.

Odynophagia is the sensation of pain on swallowing which is usually felt in the chest or throat. Globus is the sensation of a lump, fullness or tightness in the throat.

Differential diagnosis

The causes of the above types of dysphagia are shown in Tables 1.1 and 1.2.

Table 1.1 Etiology of oropharyngeal dysphagia.

• Neurological disorders
• Cerebrovascular disease
• Amyotrophic lateral sclerosis
• Parkinson's disease
• Multiple sclerosis
• Bulbar poliomyelitis
• Wilson's disease
• Cranial nerve injury
• Brainstem tumors

• Striated muscle disorders
• Polymyositis
• Dermatomyositis
• Muscular dystrophies
• Myasthenia gravis

• Structural lesions
• Inflammatory - pharyngitis, tonsillar abscess
• Head and neck tumors
• Congenital webs
• Plummer-Vinson syndrome
• Cervical osteophytes

• Surgical procedures to the oropharynx
• Pharyngeal pouch (Zenker diverticulum)
• Cricopharyngeal bar

• Metabolic disorders
• Hypothyroidism
• Hyperthyroidism
• Steroid myopathy

Table 1.2 Etiology of esophageal dyphagia.

• Neuromuscular/dysmotility disorders
• Achalasia
• CRST syndrome
• Diffuse esophageal spasm
• Nutcracker esophagus
• Hypertensive lower esophageal shincter
• Nonspecific esophageal dysmotility
• Chaga disease
• Mixed connective tissue disease

• Mechanical strictures - intrinsic
• Peptic related to GERD
• Carcinoma
• Esophageal webs
• Esophageal diverticula
• Lower esophageal ring (Schatzki)
• Benign tumors
• Foreign bodies
• Acute esophageal mucosal infections
• Pemphigus/pemphigoid
• Crohn's disease

• Mechanical lesions - extrinsic
• Bronchial carcinoma
• Mediastinal nodes
• Vascular compression
• Mediastinal tumors
• Cervical osteoarthritis/spondylosis

History and examination

Acute dysphagia is a relatively uncommon, but dramatic, presenting symptom and constitutes a gastrointestinal emergency. The patient will complain of difficulty initiating swallowing or state that food is readily swallowed but results in the rapid onset of chest discomfort or pain, which is only relieved by passage or regurgitation of the swallowed food bolus. The latter sensation can result after swallowing a mouthful of liquid. In the acute case it is important to ask the patient about the presence of other neurological symptoms.

If oropharyngeal dysphagia is suspected, the following points are important:

• The patient may complain of nasal regurgitation of liquid, coughing or choking during swallowing or a change in voice character which may indicate nasal speech due to palatal weakness.
• Patients may describe repeated attempts at the initiation of swallowing.
• Symptoms are noticed within a second of swallowing.
• Patients with cerebrovascular disease may give a history of symptoms of transient ischemic attacks (TIA) - these would include visual disturbance, dysphasia, or transient facial or limb weakness.
• There may be progressive muscular weakness and dysphagia is only part of the symptom complex, in contrast to esophageal dysphagia where swallowing disorder is the most prominent symptom.
• Patients should have a careful neurological examination and evaluation of the pharynx and larynx including direct laryngoscopy.
• In cases of esophageal dysphagia, the following points are important:
• Is the sensation of dysphagia worse with liquids or solids? If a progressive obstructive lesion is the cause of symptoms, the patient will notice difficulty swallowing solids initially and liquids later. Difficulty with both solids and liquids suggests dysmotility.
• Is the dysphagia intermittent or progressive? Intermittent dysphagia may indicate a motility disorder such as diffuse esophageal spasm whereas a progressive course is more characteristic of an esophageal tumor.
• How long have symptoms been present? A long history usually greater than 12 months suggests a benign cause, whereas a short history less than 4 weeks suggests a malignant etiology.
• Has the patient a history of heartburn suggesting gastroesophageal reflux disease (GERD)? While a history of heartburn does not rule out gastroesophageal cancer as a cause of dysphagia, a long history in the presence of slow onset, non-progressive symptoms may point to a benign peptic stricture as the cause.

A diagnostic algorithm for the symptomatic assessment of the patient with dysphagia is shown in Fig. 1.1.

Fig. 1.1 Diagnostic algorithm for the symptomatic assessment of the patient with dysphagia.

Source: Yamada 1995. Reproduced with permission of Wiley.

The etiology of esophageal dysphagia is summarized in Table 1.2.

While acute dysphagia may be painful, especially in relation to foreign body or food bolus impaction above an existing stricture, a history of odynophagia usually suggests an inflammatory condition or disruption of the esophageal mucosa leading to the irritation of pain receptors. The causes of odynophagia are:

• Candida
• herpes simplex
• cytomegalovirus
• pill-induced ulceration
• reflux disease/stricture
• radiation esophagitis
• caustic injury
• motility disorders stimulated by swallowing
• cancer
• graft-versus-host disease
• foreign body.

Clinical signs in patients who present with dysphagia are uncommon. On examination, the following signs should be noted:

• loss of weight
• signs of anemia
• cervical lymphadenopathy
• hoarseness
• concomitant neurological especially bulbar signs
• respiratory signs if history of cough/choking
• hepatomegaly
• oral ulcers or signs of Candida
• goiter.

Investigation

Dysphagia is considered to be an "alarm symptom" and should be investigated as a matter of urgency in all cases. Upper gastrointestinal endoscopy is a safe investigation in experienced hands provided the intubation is carried out under direct visualization of the oropharynx and upper esophageal sphincter. The endoscopist should be alert to the possibility of a high obstruction and the likelihood of retained food debris or saliva if dysphagia has been present for some time. If there is a history of choking, the patient should have a liquid-only diet for 24 hours followed by a 12-hour fast prior to the procedure. In some cases, the careful passage of a nasoesophageal tube to aspirate retained luminal contents may be necessary. At endoscopy, obstructing lesions can be biopsied and peptic strictures can be dilated with a balloon or bougie.

The presence of a dilated food and saliva-filled esophagus in the absence of a stricture raises the possibility of achalasia.

Barium studies are not a prerequisite for endoscopy but should be considered complementary in dysphagia. Barium swallow may give additional information in the following situations:

• in cases of suspected oropharyngeal dysphagia, especially if videofluoroscopy is employed;
• where a high esophageal obstruction is suspected prior to endoscopy;
• where a motility disorder is suspected as a method to assess lower esophageal relaxation.

In some cases, a barium swallow may be a useful investigation in certain circumstances:

• Where there is suspected proximal obstruction, e.g. laryngeal cancer, Zenker's diverticulum;
• Following a negative endoscopy or obstructive symptoms as lower esophageal rings may be more easily detected at fluoroscopy.

Esophageal manometry is indicated if both endoscopy and barium studies are inconclusive in the presence of persistent symptoms. Manometry requires intubation of the esophagus with a multilumen recording...