Dysphagia (oral and esophageal)
Dysphagia is difficulty swallowing, and the history alone localizes it to oropharyngeal disease, marked by choking or nasal regurgitation at the start of a swallow, or esophageal disease, marked by food sticking seconds later. Esophageal dysphagia with solids alone points to a mechanical obstruction worked up first with upper endoscopy, while dysphagia for solids and liquids together points to a motility disorder worked up with barium esophagram and manometry.
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What this article covers
- Overview
Definition: dysphagia is a disruption of the swallowing mechanism such that a food or liquid bolus fails to pass normally from the mouth to the stomach; it is a symptom, not a diagnosis, and the history is the first diagnostic tool.
- Epidemiology
Oropharyngeal dysphagia: most often follows stroke; prevalence rises with age and neurodegenerative disease (Parkinson disease, dementia, multiple sclerosis, ALS).
- Risk factors
Prior stroke or neurodegenerative disease: the leading risk factors for oropharyngeal dysphagia (Parkinson disease, dementia, multiple sclerosis, ALS, myasthenia gravis).
- Pathophysiology
Oropharyngeal dysphagia: neuromuscular injury (central, as in stroke, or peripheral, as in myasthenia gravis) impairs coordinated bolus formation, soft palate elevation, and epiglottic closure…
- Clinical features
Timing relative to the swallow is the key discriminator: oropharyngeal dysphagia causes difficulty within one second (coughing, choking, drooling, nasal regurgitation as the bolus is initiated)…
- Differential diagnosis
Stroke or other central neurologic disease: oropharyngeal dysphagia with other focal neurologic deficits or dysarthria; the most common cause of oropharyngeal dysphagia.
- Diagnosis
The history establishes the diagnosis before any test is ordered: distinguish oropharyngeal from esophageal dysphagia by timing relative to the swallow, then classify esophageal dysphagia as…
- Management
Oropharyngeal dysphagia: speech-language pathology swallowing exercises and diet texture modification (thickened liquids, modified solids) guided by the swallow study, plus treatment of the…
- Complications
Aspiration pneumonia: the principal danger of oropharyngeal dysphagia, from repeated tracheal soiling with oral contents.
- Prognosis
Mechanical causes generally do well once treated: dilation relieves peptic strictures and Schatzki rings promptly, though peptic strictures recur without maintenance acid suppression.
- Prevention
Maintenance acid suppression after peptic stricture dilation: omeprazole 20 mg PO once daily indefinitely; a PPI is preferred over an H2-receptor antagonist here.
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Achalasia is a primary esophageal motility disorder from myenteric plexus degeneration that causes failure of lower esophageal sphincter relaxation and aperistalsis, producing dysphagia to solids and liquids with regurgitation. Diagnosis requires endoscopy to exclude pseudoachalasia followed by esophageal manometry, and definitive treatment is pneumatic dilation, laparoscopic Heller myotomy, or POEM.
- Esophageal cancer
Esophageal cancer comprises squamous cell carcinoma, driven by tobacco, alcohol, and caustic or motility injury to the upper and mid esophagus, and adenocarcinoma, arising from GERD-driven Barrett esophagus distally, both presenting with progressive dysphagia from solids to liquids plus weight loss. Diagnosis is by upper endoscopy with biopsy, staged with CT, PET, and endoscopic ultrasound, and treatment is stage-directed from endoscopic resection through esophagectomy with perioperative chemotherapy or chemoradiation to palliative chemoradiation and stenting.
- Esophageal stricture
Esophageal stricture is a fixed luminal narrowing that produces progressive dysphagia to solids, most often a benign peptic stricture from chronic reflux but always requiring endoscopy with biopsy to exclude malignancy. Management is endoscopic dilation of the narrowed segment plus treatment of the underlying cause, with stenting or resection reserved for malignant obstruction.
- Eosinophilic esophagitis
Eosinophilic esophagitis is a chronic, immune/antigen-mediated disease of the esophagus that presents with solid-food dysphagia and food impaction in young atopic men, diagnosed by endoscopic biopsy showing 15 or more eosinophils per high-power field after excluding other causes. Management follows the three D's: dietary elimination, drug therapy with a PPI and/or swallowed topical corticosteroids, and dilation for fibrostenotic strictures.
- Zenker diverticulum
Zenker diverticulum is a pharyngoesophageal false diverticulum that herniates through Killian triangle above a hypertonic, poorly relaxing cricopharyngeus, producing oropharyngeal dysphagia, regurgitation of undigested food hours after eating, halitosis, and aspiration in older adults. Barium esophagram is the confirmatory study, blind endoscopy or nasogastric intubation must be avoided, and definitive treatment is cricopharyngeal myotomy combined with diverticulectomy, diverticulopexy, or endoscopic stapling.
- Gastroesophageal reflux disease (GERD)
GERD is retrograde reflux of gastric contents into the esophagus causing heartburn and regurgitation, diagnosed clinically and confirmed by response to an empiric PPI trial, with endoscopy reserved for alarm features or refractory symptoms. Management proceeds from lifestyle measures through an 8-week once-daily PPI trial, dose escalation or agent switch for partial response, and fundoplication for medication-refractory or regurgitation-predominant disease.