Dysphagia

Dysphagia or difficulty in swallowing is a sensation of sticking or obstruction when food passes through the mouth, pharynx or oesophagus.

It can be categorised as :

Results from neuromuscular dysfunction affecting the initiation of swallowing by pharynx and upper oesophageal sphincter.
Patient presents with difficulty initiating swallowing and may develop choking, nasal regurgitation or tracheal aspiration.
On examination, drooling (ptyalism), dysarthria, hoarseness and cranial nerve or other neurological signs may be present.
Etiology:
- Multiple sclerosis.
- Myasthenia gravis.
- Bulbar or pseudo-bulbar palsy.

Caused by structural disease (benign or malignant strictures) and dysmotility of the oesophagus.
Patient complains of food sticking after swallowing.
Etiology:
- GERD.
- Achalasia cardia.
- Hiatus hernia.

Type of Food

Difficulty only with solid food intake : Mechanical dysphagia (lumen not severely narrowed).
Solid and liquid food equally difficult to swallow : Motor dysphagia such as Achalasia cardia and diffuse oesophageal spasm.
Difficulty swallowing solid food (unrelated to posture) and dysphagia to liquids only while recumbent : Scleroderma.

Duration and Course

Transient dysphagia : Inflammatory process.
Progressive dysphagia lasting a few weeks to months : Carcinoma of the oesophagus.
Episodic dysphagia to solids lasting several years : Benign disease characteristic of lower oesophageal ring.

Site of Dysphagia

Helps to determine the site of oesophageal obstruction : Lesion is at or below the perceived location of dysphagia.

Associated Symptoms

Nasal regurgitation and tracheobronchial aspiration with swallowing : Pharyngeal paralysis or Tracheoesophageal fistula.
Tracheobronchial aspiration unrelated to swallowing : Achalasia, Zenker's diverticulum or Gastro-esophageal reflux.
Severe weight loss, out of proportion to the degree of dysphagia : Carcinoma.
Hoarseness preceding dysphagia : Lesion in the larynx.
Hoarseness following dysphagia : Involvement of recurrent laryngeal nerve by extension of oesophageal carcinoma.
Unilateral wheezing with dysphagia : Mediastinal mass involving the oesophagus and large bronchus.
Chest pain with dysphagia : Diffuse oesophageal spasm and related motor disease.
Prolonged history of heartburn and reflex preceding dysphagia : Peptic stricture.
Odynophagia : Candidal or herpes oesophagitis or pill-induced oesophagitis.

Important in motor dysphagia due to skeletal muscle, neurologic and oropharyngeal diseases.
The neck should be examined for thyromegaly or any spinal abnormality.
The mouth and pharynx should be examined for any lesions that may interfere with passage of food because of pain or obstruction.
Changes in the skin and extremities may suggest diagnosis of scleroderma and other collagen vascular diseases or mucocutaneous diseases such as pemphigoid or epidermolysis bullosa, that may involve the oesophagus.
Lymph nodes should be examined for any cancerous involvement.

Oropharyngeal dysphagia : Videofluoroscopy of the oropharyngeal swallowing.
Mechanical dysphagia:
- Barium swallow.
- Esophagogastroscopy.
- Endoscopic biopsy.
Motor dysphagia:
- Barium swallow.
- Oesophageal motility study.

Chest pain resembling diffuse oesophageal spasm may occur in oesophageal obstruction due to a large bolus.
History of prolonged nasogastric intubation, ingestion of caustic agents, ingestion of pills without water, previous radiation therapy, or associated mucocutaneous diseases may provide the cause of oesophageal stricture.
In patients with AIDS or other immunodeficiency states, oesophagitis due to opportunistic infections such as Candida, Herpes simplex or Cytomegalovirus and tumors such as Kaposi's Sarcoma and Lymphoma should be suspected.

Harrison's Principles of Internal Medicine (17th edition), Fauci, Braunwald, Jasper, Hauser, Longo, Jameson, Loscalzo, The McGraw-Hill Companies.

*This article is an excerpt from the above mentioned book and Medical Sutras does not make any ownership or affiliation claims.