Dysphagia

Background

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.

Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.

Esophagus anatomy and nomenclature based on two systems.

• Most patients with dysphagia have an identifiable, organic cause
• Assume malignancy in patients >40yo with new-onset dysphagia
• Medications can cause dysphagia from esophageal mucosal injury or reduced lower esophageal sphincter tone.
• CVA is most common cause of oropharyngeal dysphagia

Clinical Features

• Difficulty swallowing
• Sensation of food stuck
• Chest pain
• Dysphagia categories
  • Oropharyngeal dysphagia - difficulty initiating swallowing (coughing, chocking, nasal regurgitation)
  • Esophageal dysphagia
    • Mechanical obstruction - usually solid food only
    • Neuromuscular disorder - solid or liquid food

Transfer dysphagia (oropharyngeal)

• Discoordination in transferring bolus from pharynx to esophagus
• Etiology
  • Neuromuscular disease (80% of cases)
    • CVA, scleroderma, myasthenia gravis, Parkinson's, botulism, lead poisoning
  • Localized disease
    • Pharyngitis, aphthous ulcers, PTA, Zenker diverticulum
• Symptoms
  • Gagging, coughing, inability to initiate swallow, need for repeated swallows

Transport dysphagia (esophageal)

• Improper transfer of bolus from upper esophagus into stomach
• Etiology
  • Obstructive disease (85% of cases)
    • Foreign body, carcinoma, webs, strictures, thyroid enlargement
  • Motor disorder
    • Achalasia, peristaltic dysfunction (nutcracker esophagus), scleroderma
• Symptoms
  • Food "sticking," retrosternal fullness with solids (and eventually liquids), odynophagia

Differential Diagnosis

Dysphagia

• Oropharyngeal dysphagia
  • CVA
  • Parkinson's disease
  • Brain stem tumors
  • Degenerative disease - ALS, MS, Huntington's
  • Postinfectious - polio, syphilis
  • Peripheral neuropathy
  • Myasthenia gravis
  • Polymyositis, dermatomyositis
  • Muscular dystrophy
• Esophageal dysphagia
  • Achalasia
  • Diffuse esophageal spasm
  • Ingested foreign body
  • Esophageal web
  • Malignancy, mediastinal masses
  • Schatzki Ring
  • Scleroderma
  • Strictures - peptic, radiation, chemical, medication-induced
  • Vascular compression
  • Zenker's diverticulum

Evaluation

• Evaluate for underlying etiology (e.g. rule out new neuro dysfunction)
• Neck x-ray (AP and lateral)
  • Helpful in presumed transfer dysphagia and proximal transport dysphagia
• CXR
  • Helpful in presumed transport dysphagia

Management

• Referral to GI or ENT for direct laryngoscopy or video-esophagography