Dysphagia

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Background

  • 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

Differential Diagnosis

Dysphagia

Evaluation

Must distinguish between transfer dysphagia and transport dysphagia

Work-Up

  • Neck x-ray (AP and lateral)
    • Helpful in presumed transfer dysphagia and proximal transport dysphagia
  • CXR
    • Helpful in presumed transport dysphagia

Evaluation

Transfer dysphagia (oropharyngeal)

  • Discoordination in transferring bolus from pharynx to esophagus
  • Etiology
    • Neuromuscular disease (80% of cases)
      • CVA, scleroderma, MG, 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, stricures, thyroid enlargement
    • Motor disorder
      • Achalasia, peristaltic dysfunction (nutcracker esophagus), scleroderma
  • Symptoms
    • Food "sticking," retrosternal fullness with solids (and eventually liquids), odynophagia

Management

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

Disposition

See Also

References