is a medical term defined as "difficulty swallowing". It derives from the Greek root ''dys'' meaning difficulty or disordered, and ''phagia'' meaning to eat. It is a sensation that suggests difficulty in the passage of solids or liquids from the
Mouth to the
Stomach Sleisinger and Fordtran's Gastrointestinal and Liver Disease, 7th edition, Chapter 6, p. 63 . Dysphagia is distinguised from similar symptoms including '''
Odynophagia ''', which is defined as painful swallowing, and
Globus , which is the senation of a lump in the throat. It is also worthwhile to refer to the
Physiology Of Swallowing in understanding dysphagia.
Dysphagia is a common or chronic care facilities. It is a symptom whose cause can usually be elicited by a careful
History by the treating
Physician Schatzki R. Panel discussion on diseases of the esophagus. Am J Gastro. 31:117 (1959). .
Dysphagia is classified into two major types: dysphagia (or '''transfer''' dysphagia) and '''esophageal''' dysphagia. In some patients, no organic cause for dysphagia can be found, and these patients are defined as having '''functional''' dysphagia.
Arises from abnormalities of the upper esophagus and the pharynx.
Patients usually experience food getting stuck ''immediately'' after swallowing, nasal regurgitation, or even difficulty initating a swallow, and will point to the cervical (neck) region as the site of the obstruction.
''Neurologic disorders'' such as
Stroke ,
Parkinson's Disease ,
Amyotrophic Lateral Sclerosis ,
Bell's Palsy , or
Myasthenia Gravis can cause weakness of facial and lip muscles that are involved in coordinated mastication.
''Decrease in salivary flow'' can be due to
Sjogren's Syndrome ,
Anticholinergics ,
Antihistamines , or certain
Antihypertensives and can lead to incomplete processing of food bolus.
''Poor dentition'' can lead to inadequate mastication.
''Abnormality in oral mucosa'' such as from
Mucositis ,
Aphthous Ulcers , or
Herpetic Lesions can interfere with bolus processing.
''Mechanical obstruction'' in oropharynx may be due to malignancies, cervical rings or webs, or cervical osteophytes.
''Increased upper esophageal sphincter tone'' can be due to
Parkinson's Disease which leads to incomplete opening of the UES. This may lead to formation of a
Zenker's Diverticulum .
Arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach. Usually due to mechanical causes or motility problems.
Patients usually experince food getting stuck ''several seconds'' after swallowing, and will point to the suprasternal notch or behind the sternum as the site of obstruction. If there is dysphagia to both solids and liquids, then it is most likely a motility problem. If there is dysphagia initially to solids but progresses to also involve liquids, then it is most likely a mechanical obstruction. Once motility vs mechanical causes have been distinguished, it is important to note whether the dysphagia is intermittent or progressive. An intermittent motility dysphagia most likely can be
Diffuse Esophageal Spasm (DES) or nonspecific esophageal motility disorder (NEMD). Progressive motility dysphagia include
Scleroderma or
Achalasia with chronic heartburn, regurgitation, respiratory problems, or weight loss. An intermittent mechanical dysphagia is likely to be an
Esophageal Ring . Progressive mechanical dysphagia is most likely due to
Peptic Stricture or
Esophageal Cancer .
'', or narrowing of the esophagus, is usually a complication of acid reflux, most commonly due to
Gastroesophageal Reflux (
GERD ). These patients are usually older and has had GERD for a long time. Acid reflux can also be due to other causes, such as Zollinger-Ellison syndrome, NG tube placement, and scleroderma. Other non-acid related causes of peptic strictures include infectious esophagitis, ingestion of chemical irritant, pill irritation, and radiation. Peptic stricture is a progressive mechanical dysphagia, meaning patients will complain of initial intolerance to solids followed by inability to tolerate liquids. Usually the threshold to solid intolerance is 13 mm of the esophageal lumen. Symptoms relating to the underlying cause of the stricture usually will also be present.
See Also: peptic stricture
'' also presents with progressive mechanical dysphagia. Patients usually come with
rapidly progressive dysphagia first with solids then with liquids, weight loss (> 10 kg), and anorexia (loss of appetite). Esophageal cancer usually affects the elderly. Esophageal cancers can be either squamous cell carcinoma or adenocarcinoma. Adenocarcinoma is the most prevalent in the US and is associated with patients with chronic GERD who has developed
Barrett's Esophagus (intestinal metaplasia of esophageal mucosa). Squamous cell carcinoma is more prevalent in Asia and is associated with tobacco smoking and alcohol use.
See Also: esophageal cancer
'', as the name suggests, are actual rings and webs of tissue that may occlude the esophageal lumen.
- ''Rings'' --- Also known as Schatzki rings from the discoverer, these rings are usually mucosal rings rather than muscular rings, and are located near the gastroesophageal junction at the squamo-columnar junction. Presence of multiple rings may suggest Eosinophilic Esophagitis . Rings are intermittent mechanical dysphagia, meaning patients will usually present with transient discomfort and regurgitation while swallowing solids and then liquids, depending on the constriction of the ring.
- ''Webs'' --- Usually squamous mucosal protrusion into the esophageal lumen, especially anterior cervical esophagus behind the cricoid area. Patients are usually asymptomatic or have intermittent dysphagia. An important association of esophageal webs is to the Plummer-Vinson Syndrome in Iron Deficiency , in which case patients will also have anemia, koilonychia, fatigue, and other symptoms of Anemia .
See Also: esophageal rings and webs
'' is an idiopathic motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation as well as loss of peristalsis in the distal esophagus (which is mostly smooth muscle). Both of these features impairs the ability of the esophagus to empty contents into the stomach. Patients usually complain of dysphagia to both solids and liquids. Dysphagia to liquids is most characteristic of achalasia. Other symptoms of achalasia include weight loss, regurgitation, chest pain, hiccups, and heartburn. The combination of achalasia, adrenal insufficiency, and alacrima (lack of tear production) in children is known as the triple A (Allgrove) syndrome. Achalasia can also be due to
Chaga's Disease from infection by ''Trypanosoma cruzi''.
See Also: achalasia
'' is a disease characterized by atrophy and sclerosis of the gut wall, most commonly of the distal esophagus (~90%). Consequently, the lower esophageal sphincter cannot close and this can lead to severe gastroesophageal reflux disease (GERD). Patients typically present with progressive dysphagia to both solids and liquids secondary to motility problems or peptic stricture from acid reflux.
See Also: scleroderma
'' include
Diffuse Esopahgeal Spasm (DES),
Nutcracker Esophagus ,
Hypertensive Lower Esophageal Sphincter , and nonspecific spastic esophageal motility disorders (NEMD).
- ''DES'' can be caused by many factors that affect muscular or neural functions, including acid reflux, stress, hot or cold food, or carbonated drinks. Patients present with intermittent dysphagia, chest pain, or heartburn.
''
Once esophageal dysphagia has been implicated in a patient, next step is to determine whether to directly proceed to a ''
Barium Swallow '' or an ''
Upper Endoscopy ''. Any suspicion for a proximal lesion such as:
- history of surgery for laryngeal or esophageal cancer
- history of radiation or irritating injury
- achalasia
- Zenker's diverticulum
should be proceeded to a barium swallow first instead of endoscopy to prevent any perforation. If achalasia suspected on barium swallow, proceed to manometry to confirm. If a stricture is suspected, proceed to endoscopy. Any other lesions found should be treated as such.
If there's no suspicion for any of the above lesions, endoscopy can be proceeded directly. Any structural or mucosal abnormality should be treated. A normal endoscopy should be followed by manometry. If manometry is normal, patients are diagnosed with
Functional Dysphagia .
Treatment is directed at the underlying causes. (see above)
Vitalstim Therapy (
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GI, pulmonary, ENT, or oncology consult is usually sent depending on suspicion of underlying cause. A consultation is usually sent for a dietician because many patients cannot have a proper diet due to inability to ingest solids or liquids. Speech therapist may be needed for those with oropharyngeal dysphagia.
