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Dysphagia

Last updated: October 19, 2021

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Dysphagia is a nonspecific symptom that refers to difficulty in swallowing. When present, it should be considered a red flag feature for a potentially serious underlying condition and should be evaluated thoroughly. Oropharyngeal dysphagia refers to difficulty in initiating the swallowing process and is typically associated with coughing or choking. Esophageal dysphagia refers to the impaired passage of a food bolus from the esophagus to the stomach. Dysphagia predominantly with solid foods is usually caused by a mechanical obstruction (e.g., esophageal stricture, oropharyngeal abscess). Dysphagia with liquids and solid food typically indicates a neuromuscular disorder (e.g., esophageal motility disorders, neurodegenerative conditions). Acute dysphagia is commonly caused by food bolus impaction or stroke. Depending on the suspected etiology, the diagnostic workup can include an endoscopic evaluation of the nasopharynx and/or esophagus, a barium swallow, and high-resolution manometry. Neuroimaging and laboratory studies should also be considered as needed. Supportive therapy (e.g., swallowing rehabilitation, measures to minimize aspiration risk) is the mainstay of management, especially in patients with oropharyngeal dysphagia; etiology-specific management (e.g., esophageal dilation, antimicrobials for infectious esophagitis) may be feasible in some conditions. In elderly patients with dysphagia, goals of care should be discussed before considering interventional management.

  • Dysphagia: any difficulty swallowing, which can be divided into the following subtypes
    • Oropharyngeal dysphagia: difficulty initiating the swallowing process
    • Esophageal dysphagia: the impaired passage of solid food and liquid through the esophagus towards the stomach
    • Motility-related dysphagia: dysphagia due to a neurological or muscular defect
    • Structural dysphagia: dysphagia due to a mechanical or anatomical obstruction
  • Aphagia: the inability to swallow
  • Presbyphagia: the characteristic changes and mild decline in swallowing function seen in older adults; typically asymptomatic [1]
  • Odynophagia: a painful sensation triggered by swallowing

References: [2][3]

The following table provides an overview of the etiologies of nonacute dysphagia. Food bolus impaction is a common cause of acute dysphagia but is often triggered by an underlying esophageal etiology.

Dysphagia should be distinguished from xerostomia, globus pharyngeus, and presbyphagia. [7]

Do not assume a diagnosis of presbyphagia in elderly patients with difficulty swallowing. Dysphagia is an alarm symptom and should be investigated thoroughly to determine its underlying etiology and start appropriate treatment.

A detailed clinical history and physical examination in patients with dysphagia can help categorize symptoms and select the best initial diagnostic test.

Clinical evaluation [5][6][8]

Oropharyngeal dysphagia should be identified promptly, as it increases the risk of aspiration. Oropharyngeal dysphagia and esophageal dysphagia may occur simultaneously. [6]

Acute dysphagia can be caused by food impaction or a stroke and requires prompt evaluation.

Characterization of dysphagia

Clinical characterization of dysphagia [2][5][9]
Description of dysphagia Possible associated findings and conditions
Oropharyngeal dysphagia
  • Difficulty initiating swallowing, which can lead to repeat swallow attempts
  • Predominantly experienced in the throat or neck
  • May be associated with coughing or a choking sensation early in the swallowing process.
Esophageal dysphagia
  • Symptoms occur seconds after swallowing
  • Predominantly experienced retrosternally
  • May be associated with coughing late in the swallowing process
Motility-related dysphagia
  • Dysphagia predominantly with liquids (or liquids and solid food)
  • May be aggravated by cold foods
  • Intermittent symptoms or progression of symptoms over a long duration (months to years) [5]
Structural dysphagia
  • Dysphagia predominantly with solid food (or initially to solids that progressed to liquids)
  • May be aggravated by large food boli and dense food

Dysphagia predominantly with solid food should raise suspicion for an underlying structural disorder, including malignancy. Dysphagia predominantly with liquids is suggestive of an esophageal motility disorder. [2]

Red flags for dysphagia [2][6][8]

Dysphagia is an alarm feature itself and should be evaluated thoroughly. However, the following features should raise suspicion for malignancy as the underlying etiology.

Elderly patients with recent pneumonia should be screened for dysphagia. [8]

Initial diagnostics [5][8]

See dedicated sections below for details.

Etiology

Common etiologies of oropharyngeal dysphagia [2][7]
Characteristic clinical features Diagnostics
Neuromuscular disorders CNS disorders

Muscular disorders
[10][11]

  • Dysphagia predominantly with liquids
  • Subacute onset
  • Usually associated with systemic features of progressive weakness
  • FEES and manometry
    • Weak pharyngeal muscle contraction
    • Ineffective swallow
    • Pharyngeal food residue
    • Velopharyngeal insufficiency may be present

Obstructive and structural causes

External compression
[12]

  • Visible or palpable masses in the neck or oropharynx may be present
  • Additional features depend on the specific etiology.

Head and neck malignancies [13]

  • Endoscopy (e.g., nasopharyngeal laryngoscopy): visualization of the tumor
  • Imaging (e.g., CT, MRI, or PET) of the head and neck: localize the site of oropharyngeal compression; assess the extent of the tumor
Secondary to treatment, interventions, or injury [14][15]
Zenker diverticulum [3]

Oropharyngeal dysphagia is commonly caused by neuromuscular and systemic conditions.

Diagnostics [2][6][8]

A multidisciplinary evaluation involving speech-language pathologists, neurologists, and otolaryngologists is recommended for a comprehensive evaluation.

Consider EGD to rule out an esophageal etiology for dysphagia in patients in whom an oropharyngeal etiology has been ruled out.. [8]

Treatment [8][16][17]

Management is primarily supportive and should be tailored to each patient, focus on symptom control, minimize aspiration risk, and ensure adequate nutrition. Goals of care should be discussed before considering interventional therapy (including enteral feeding) for dysphagia in elderly patients.

Etiology

Common etiologies of esophageal dysphagia [5][8]

Characteristic clinical features Diagnostics Management
Esophagitis
(most common cause of dysphagia) [5][8][12]
  • Depends on the underlying cause
  • See “GERD” and “Esophagitis” for details.
Functional esophageal disorders (e.g., nonerosive reflux disease, reflux hypersensitivity) [8]
  • A diagnosis of exclusion

Structural and obstructive disorders

Esophageal cancer [2][23]
Esophageal strictures [5][24]
  • Dysphagia predominantly with solid food [5]
  • Symptoms may be intermittent or persistent [2][5][12]
  • Dilation with a bougie dilator or balloon dilator
  • Treatment of the underlying cause
Esophageal webs or esophageal rings [12]
  • Intermittent dysphagia predominantly with solid food [2]
  • Prolonged duration of symptoms
Esophageal diverticula [12]
  • May be asymptomatic depending on the location
  • Regurgitation of undigested food
  • Halitosis
Extrinsic compression
[8][12]
  • Dysphagia predominantly with solid food
  • Features of the underlying condition
  • Treatment of the underlying cause

Motility-related disorders (uncommon) [5][6][8]

Esophageal hypermotility disorders [12][26]
  • Intermittent dysphagia, predominantly with liquids
  • Episodic retrosternal chest pain
  • In some cases, heartburn and/or regurgitation
Achalasia [2][5][27]
  • Dysphagia with liquid and solid food
  • Slow onset; symptoms often last for months to years [12]
  • Retrosternal pain
  • Regurgitation of undigested food
  • Weight loss
  • Halitosis

Scleroderma

[5][28]

  • Slow onset [12]
  • Progressive dysphagia [5]
  • In some cases, heartburn, regurgitation, weight loss, and other symptoms of CREST syndrome [2]

Opioid use can cause esophageal hypomotility and thereby dysphagia (opioid-induced esophageal dysfunction). [8]

Diagnostics [5][6][8]

Consult a gastroenterologist early for a comprehensive evaluation. [2]

In patients < 50 years of age with characteristic features of GERD and no alarm features for malignancy, a trial of empiric treatment with PPIs for 4 weeks may be considered. Persistent dysphagia despite empiric treatment necessitates evaluation by EGD. [2][8]In all patients with unexplained solid food dysphagia, biopsies should be obtained from normal-appearing mucosa of the mid-third and distal esophagus to evaluate for eosinophilic esophagitis. [8]

Treatment [2][8][17]

Depends on the underlying cause. See “Overview of esophageal dysphagia” and dedicated articles for details; examples include:

In older patients, discuss goals of care before considering interventional therapy. [8]

  • Clinical features [32][33]
    • Acute dysphagia, often after eating meat
    • Aphagia and drooling indicates complete esophageal obstruction.
  • Management: prompt endoscopic removal of the bolus [32][33]
    • IV glucagon for esophageal relaxation may be trialed but should not delay endoscopic intervention.
    • Complete obstruction: emergency endoscopy
    • Incomplete obstruction: urgent endoscopy, ideally within 24 hours
    • The impacted bolus may either be extracted perorally or broken into smaller pieces and gently pushed into the stomach.
    • The esophageal mucosa should be evaluated to determine if an underlying structural pathology triggered the impaction.
    • If no structural pathology is identified, multilevel biopsies should be obtained to assess for eosinophilic esophagitis.

Food bolus impaction is often associated with an underlying esophageal disease, e.g., eosinophilic esophagitis. [32][33]

Esophageal food bolus impaction partially or completely obstructs the esophagus and should be treated promptly to avoid complications, such as a perforation, esophagitis, or fistula formation. [32][33]

We list the most important complications. The selection is not exhaustive.

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