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Clinical Conditions-Dysphagia

Written by Wesam Tamimi, M.D.

Keywords: Dysphagia, swallowing difficulty, oropharyngeal dysphagia, esophageal dysphagia, barium swallow, esophagogastroduodenoscopy.

Buzzwords Scenario: A 67-year-old man presents with difficulty swallowing solid foods for the past 6 months, progressively worsening to include liquids. He reports unintentional weight loss and occasional coughing after eating. Physical examination reveals no significant abnormalities.

Overview

Dysphagia, or difficulty swallowing, is a clinical symptom that can arise from a variety of underlying conditions. It is typically classified into two categories: oropharyngeal dysphagia, which affects the initiation of the swallowing process, and esophageal dysphagia, which occurs within the esophagus. Dysphagia can be caused by structural abnormalities, motility disorders, or neurologic conditions. Early recognition and diagnosis are crucial for preventing complications such as aspiration pneumonia, malnutrition, and dehydration.

Definitions

Dysphagia is characterized by difficulty in swallowing, which may affect the oral, pharyngeal, or esophageal phases of the swallowing process.

Aphagia: Complete inability to swallow, often due to esophageal obstruction, typically seen in acute settings involving food bolus or foreign body impaction.

Odynophagia: Painful swallowing usually caused by mucosal ulceration in the oropharynx or esophagus, often accompanied by dysphagia.

Classifications

Table 1: Classification and Causes of Dysphagia

Type of dysphagia	Description	Causes
Oral dysphagia	Difficulty in forming and controlling the food bolus in the mouth.	Neurologic disorders (e.g., stroke), muscular disorders, missing dentition.
Pharyngeal dysphagia	Difficulty in the pharyngeal phase of swallowing, including bolus propulsion through the pharynx.	Neurologic disorders, structural lesions (e.g., Zenker's diverticulum), infections, and cancers.
Esophageal dysphagia	Difficulty in the esophageal phase, including bolus transit through the esophagus.	Structural causes (e.g., Schatzki rings, eosinophilic esophagitis), motility disorders (e.g., achalasia).

Etiology

Table 2: Causes of Dysphagia

Cause	Description
Structural causes	Physical obstructions or narrowing of the esophagus such as schatzki rings, peptic strictures.
Motility disorders	Abnormal esophageal contractions or peristalsis, including achalasia and diffuse esophageal spasm.
Neurologic disorders	Conditions affecting the nervous system, such as stroke or Parkinson's disease.
Iatrogenic causes	Dysphagia resulting from surgical or radiation treatments, especially in head and neck cancers.
Infectious causes	Infections causing esophageal inflammation, like Candida or herpes simplex virus.
Metabolic causes	Conditions like scleroderma that affect esophageal function.

Physiology

Swallowing is initiated voluntarily in the oral phase, involving mastication and mixing of food with saliva. The bolus is then pushed into the pharynx, triggering the pharyngeal swallow response. This complex series of actions propels the bolus through the pharynx and esophagus while preventing aspiration. Key muscles and nerves involved include:

● Oral cavity muscles: Innervated by cranial nerves V (trigeminal) and VII (facial).

● Tongue: Innervated by cranial nerve XII (hypoglossal).

● Pharyngeal muscles: Innervated by cranial nerves IX (glossopharyngeal) and X (vagus).

Pathophysiology

Oropharyngeal dysphagia:

● Neurological impairment → Reduced muscle control → Difficulty initiating swallowing → Risk of aspiration.

Esophageal dysphagia:

● Structural obstruction or motility dysfunction → Impaired passage of food → Sensation of obstruction, regurgitation.

Clinical features

Table 3: Signs and symptoms of dysphagia according to cause

Disease	Signs and Symptoms
Stroke	- Sudden onset of dysphagia - Difficulty swallowing both solids and liquids - Coughing or choking while eating - Facial droop or difficulty speaking
Parkinson's disease	- Progressive dysphagia - Difficulty initiating swallowing - Drooling due to impaired control of saliva
Multiple sclerosis	- Variable onset of dysphagia - Difficulty with both solids and liquids - Weakness in the throat muscles - Fatigue affecting swallowing ability
Esophageal cancer	- Progressive dysphagia - Weight loss - Persistent cough or hoarseness - Pain or discomfort in the chest - Possible regurgitation of food
Achalasia	- Gradual onset of dysphagia - Difficulty swallowing solids more than liquids - Regurgitation of undigested food - Chest pain or discomfort - Weight loss -Bird peak appearance on barium swallow (Figure 1)
Zenker's diverticulum	- Halitosis (bad breath) - Regurgitation of undigested food - Chronic cough - Sore throat - Possible neck swelling or mass -Pouch in the esophageal wall (Figure 2)
Scleroderma	- Progressive dysphagia - Heartburn or acid reflux - Dry mouth - Skin changes (tightness) - Difficulty with both solids and liquids
Esophageal stricture	- Gradual onset of dysphagia - Painful swallowing (odynophagia) - Difficulty swallowing solids - Possible regurgitation - Weight loss
Eosinophilic esophagitis	- Dysphagia that may worsen with solid food - Chest pain or discomfort - Food impaction - Allergic symptoms or history of atopy - Possible food regurgitation

Figure 1. Bird peak appearance in esophageal achalasia

Farrokhi, F., & Vaezi, M. F. (2007, October 21). Barium swallow. Dilated esophagus with retained column of barium and “bird’s beaking” suggestive of achalasia [Photograph]. Wikimedia Commons. Idiopathic (primary) achalasia. Orphanet Journal of Rare Diseases, 2:38. https://commons.wikimedia.org/wiki/File:Acha.JPG

Figure 2. Esophageal pouch seen in a patient with Zenker's diverticulum

Heilman, J. (2012, September 19). Lateral X-ray of a Zenker's diverticula [Photograph]. Wikimedia Commons. Own work. https://commons.wikimedia.org/wiki/File:Zenker22015Lateral.JPG

Diagnosis

Endoscopy (Esophagogastroduodenoscopy - EGD):

● Purpose: Direct visualization of the esophagus, stomach, and duodenum; allows for biopsy and therapeutic interventions.

● Indication: Primarily used for structural dysphagia.

● Advantages: High sensitivity for detecting mucosal lesions, Barrett's metaplasia, and vascular lesions. Allows biopsy and dilation of strictures.

Radiography (Barium swallow):

● Purpose: Contrast imaging of the esophagus and surrounding structures.

● Advantages: Effective for detecting reflux, hiatal hernia, mucosal abnormalities, and esophageal strictures, especially with barium tablets. Useful for visualizing tracheoesophageal fistulas and post-surgical anatomy.

Esophageal manometry:

● Purpose: Measures esophageal pressure and motility.

● Indication: Used for propulsive dysphagia.

● Advantages: Diagnoses motility disorders (e.g., achalasia, diffuse esophageal spasm), and assesses peristaltic integrity. High-resolution manometry and impedance monitoring enhance diagnostic accuracy.

Differential diagnosis of dysphagia

First step is to differentiate between:

● Dysphagia localized to neck, nasal regurgitation, aspiration → oropharyngeal dysphagia →Illustration 1

● Dysphagia localized to chest or neck, food impaction → esophageal dysphagia → Illustration 2

Illustration 1. Oropharyngeal dysphagia differential diagnosis

Illustration 2. Esophageal dysphagia differential diagnosis

Management

Treatment depends on the underlying cause.

Table 4: Management of dysphagia

Cause	Treatment
Neurologic disorders	Swallow therapy, postural adjustments, enteral feeding if necessary.
Structural causes	Endoscopic dilation, surgical intervention if indicated.
Motility disorders	Medical management (e.g., nitrates for diffuse esophageal spasm), surgery for achalasia.
Infectious causes	Antimicrobial treatment, management of immunosuppressive conditions.
Metabolic causes	Dietary modifications, treatment of underlying systemic conditions (e.g., scleroderma).