Dysphagia

Overview

Definitions

  • Dysphagia: Difficulty swallowing

  • Odynophagia: Painful swallowing that may be associated with dysphagia.

    • May be associated with dysphagia.

    • Consider EGD to evaluate for

      • Esophagitis (e.g. eosinophilic)

      • Post-surgical complications

Evaluation: Barium swallow → EGD → manometry

  • Concern for aspiration (e.g. s/p stroke): Obtain video fluoroscopy before barium swallow

  • Barium swallow assess motility and reveals obstructive lesions

  • EGD detects inflammation/erosion/infection and allows for biopsy

  • Manometry may reveal motility disorder missed on barium swallow

Motility Disorders (Solids + Liquids)

  • Sudden onset: Stroke-related deficits

  • Progressive symptoms: Neuromuscular motility disorder

    • Esophageal motility disorders (most common)

      • Esophageal spasm: Omeprazole 20 mg qd for GERD and peppermint oil for dysmotility. Diltiazem 60 mg q6h for refractory symptoms. Consider GI referral.

      • Scleroderma: Chronic heartburn, Renaud’s phenomenon, bloating, and alternating diarrhea/constipation. Skin thickening on fingers, hands, and face. Interstitial lung disease on CT chest. Obtain CBC, CMP, CK, U/A, ANA, anti-Scl-70 antibody, anticentromere antibody, and anti-RNA polymerase III antibody if suspected. Start omeprazole 20 mg BID for GERD. Trial of metoclopramide for refractory dysphagia symptoms. Refer to rehumatology for immunosuppressive therapy.

      • Achalasia: Frequent regurgitation and symptoms that improve with repeat swallowing

    • Oropharyngeal dysphagia due to neuromuscular disease

Mechanical Obstruction (Solids Only)

  • Pediatric or history of mental illness: Rule out foreign body ingestion

  • Intermittent symptoms

    • Esophageal web

    • Esophageal ring (Schatzki ring)

    • Zenker’s diverticulum: Halitosis with regurgitations of old food

  • Progressive symptoms

    • Stricture

      • Peptic

      • Radiation

      • Medications: NSAIDs, bisphosphonates, antibiotics (tetracyclines and sulfa derivatives)

    • Extra-esophageal compression

      • Left atrial enlargement

      • Vascular compression

      • Mediastinal mass

    • Malignancy: Patient age > 50 years. Weight loss and no regurgitation (as compared to achalasia).