Dysphagia

Background

• Most patients with dysphagia have an identifiable, organic cause
• Assume malignancy in patients >40yo with new-onset dysphagia

Clinical Features

• Difficulty swallowing
• Sensation of food stuck
• Chest pain

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

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