Dysphagia

Contents
• Definition
• Anatomy of oropharynx and esophagus
• Physiology of swallowing
• Causes of dysphagia
• Clinical approach
• Investigation
• treatment
definition
• Dysphagia means difficulty of swallowing, which is either difficulty in
initiating a swallow (oropharyngeal phase), which is under voluntary
control and most of it are due to chronic neurological or muscular
diseases or ENT problems or it’s esophageal phase which occurs
involuntarily, and patient feels sensation of food stuck.
Oropharyngeal Dysphagia
• Cerebrovascular disease (CVA)
• Parkinsonism
• Dementia
• Myasthenia gravis
• oropharyngeal cancer
• Infections e.g., retropharyngeal abscess
• goiter
• head and neck malignancy
Esophageal Dysphagia
1. Extra-mural causes:
a. Mediastinal disease (lung cancer, lymphoma)
b. Infections (TB, histoplasmosis)
c. Cardiovascular (dilated auricle, vascular compression)
2. Mural causes:
a. Esophageal rings and webs
b. Peptic stricture
c. Esophageal tumors
d. Achalasia
 e. Post surgical after fundoplication, antireflux
f. Motility disorders of esophagus
g. Strictures due to chemicals, radiaton
h. Infectious esophagitis
i. Scleroderma
3. Intra-luminal cause:
Foreign body swallowing
How to approach dysphagia
• KEY DECISION: is the dysphagia oropharyngeal or esophageal?
• This distinction may be confidently made on the basis of careful
history, which provides an accurate assessment of the type of
dysphagia (oropharyngeal vs. esophageal in about 80– 85% of cases).
How to approach dysphagia cases
• History: it is important to differentiate between oropharyngeal
dysphagia (inability to initiate the process of swallowing), most of
them are old age with history of neurological and muscular disease, or
ENT problems.
• Esophageal dysphagia: patient feels food stuck, also called low
dysphagia. So, ask about:
1. Age of patient
2. Onset of dysphagia: sudden or progressive
3. Dysphagia for liquids, or solids, or both
4. Duration of dysphagia
5. Dysphagia is intermittent or continuous
6. Halitosis
7. Loss of weight, anemia
8. History of heart burn
9. Dysphagia associated with chest pain
Associated Symptoms:
• Regurgitation
• Pain on swallowing
• Hoarseness of voice
• Otalgia
• Coughing after eating
• Frequent chest infections
Age: Possible causes
• Children: Foreign body, Congenital malformation
• Middle-aged patients: Reflux esophagitis, Hiatus hernia, Anemia,
Achalasia, Globus syndrome.
• Elderly patients: Malignancy, stricture formation from longstanding
reflux, pharyngeal pouch, motility disorders associated with aging and
neurological disorders.
• Mostly, dysphagia which starts for both solid and liquid has a benign
cause. While if it started for solid and increasing for liquids, it has
mechanical, meaning malignant, causes.

• Esophageal dysphagia can also be called “low” dysphagia, referring to

a likely location in the distal esophagus, although it should be noted
that some patients with esophageal dysphagia, such as achalasia, may
describe it in the cervical region mimicking oropharyngeal dysphagia.
• Dysphagia that occurs equally with solids and liquids, often involves
an esophageal motility problem. This suspicion is reinforced when
intermittent dysphagia for solids and liquids is associated with chest
pain.

• Dysphagia that occurs only with solids but later with liquids suggests
the possibility of mechanical obstruction with luminal stenosis to
diameter <15 mm.
• If progressive, consider particularly peptic stricture or carcinoma.
Furthermore, it is worth noting that patients with peptic strictures
usually have a long history of heartburn and acid regurgitation, but no
weight loss. Conversely, patients with esophageal cancer tend to be
older men with marked weight loss.
• If progressive, consider particularly peptic stricture or carcinoma.
Furthermore, it is worth noting that patients with peptic strictures
usually have a long history of heartburn and acid regurgitation, but no
weight loss. Conversely, patients with esophageal cancer tend to be
older men with marked weight loss.
 Dysphagia to solids or solids & liquids
Below sternal notch
Sometimes coughing after swallowing

Esophageal

Solids & liquids Solids only

Motility Acute Intermittent Progressive

problem
Progressive Intermittent Foreign body Ring Acid >50 y/o

Regurgitation Acid Chest pain

GERD Cancer

Achalasia Scleroderma Esophageal spasm

Endoscopy

Barium swallow
 Clinical Examination
Complete head and neck examination:
• Inspection of oral cavity
• Dentition
• Oropharynx
• IDL (indirect laryngoscopy)
• Nasolaryngoscopy
• Cranial nerve examination (tongue, gag and cough reflex, hoarseness,
vocal cord mobility)
• Neck for lymph nodes, neck masses, thyroid enlargement, loss of
laryngeal crepitus and integrity of laryngeal cartilages.
 Special Investigations
• Blood tests to exclude anemia (Cause or effect?)
• ESR or C-Reactive Protein raised in malignancy or chronic
inflammatory process
• LFT, RFT along S. Calcium when nutrition is impaired, or metastasis
is suspected
• Thyroid function tests if dysphagia is caused by goiter or malignancy
of thyroid
 Special Investigations
• Barium swallow
• Chest radiograph
• CT scan examination of neck, chest and abdomen.
• MRI is indicated when there are neurological causes such as multiple
sclerosis, cerebral tx, nasopharyngeal cancer.
• Rigid endoscopy
• Flexible endoscopy
• Manometry
Barium swallow (normal esophagus)
Radiological findings in dysphagia
Achalasia Carcinoma of esophagus
Barium swallow
Corkscrew Corrosive stricture
Barium swallow
Peptic stricture Ca bronchus (extramural)
Barium swallow
Esophageal web Zinker diverticulum
2. Endoscopy (Esophagoscopy)
3. Esophageal manometry
4. Radionuclide esophageal scintigraphy
5. Dynamic barium study
6. CT scan
7. MRI
1. Carcinoma of esophagus
2. Achalasia
3. GERD
4. Esophageal webs and rings
Carcinoma of esophagus
• It is the 6th cancer which affects the GIT, and most of cases are diagnosed late, i.e., it is
inoperable at the time of diagnosis, that’s why only 5-10 % will survive for 5 years.
• It is mainly of 2 types either:
1. squamous cell carcinoma:
• occurs in upper 2/3rd
• Worldwide, squamous cell cancer is most common
• etiological factors are tobacco and alcohol
2. Adenocarcinoma:
• occurs in lower 1/3rd of esophagus
• adenocarcinoma predominates in the west and is increasing in incidence
• etiological factors are GERD and obesity
3. Other rare types.
• Squamous type is decreasing while the adenocarcinoma is increasing
due to increase of obesity and GERD which is risk factor to Barret
esophagus which is a sort of metaplasia of lower esophageal mucosa
epithelium then it may progress to dysplasia and then to carcinoma.
• The cause of ca esophagus is unclear but certain risk factors increase
the incidence as followings:
1- smoking
2- alcohol consumption
3- hot drinks
The incidence of cancer in both lower esophagus and cardiac region of
stomach is increasing due to share of same etiological factor, 60-70%
occur in this region.
Metastasis
I. Direct spread of tumor both:
• Longitudinally within the esophageal wall via the submucosal
lymphatic channels of the esophagus.
• The pattern of lymphatic drainage is therefore not segmental, as in other parts
of the GI tract.
• Consequently, the length of esophagus involved by tumor is frequently much
longer than the macroscopic length of the malignancy at the epithelial surface.
• laterally to nearby structures.
II. Lymph node spread:
• predominantly caudal
• cranial direction to mediastinal LN and celiac LN
III. Hematogenous spread: including the liver, lungs, brain and bones.
IV. Trans-peritoneally: In tumors arising from the intra-abdominal
portion of the esophagus.
Clinical Features
• Usually starts with dysphagia for solid food then progresses to liquids
• Odynophagia
• Regurgitation
• Vomiting
• Loss of weight
• It may present with signs and symptoms of secondary metastasis:
1. Hoarseness of voice due to involvement of recurrent laryngeal
nerve
2. diaphragmatic paralysis
3. Horner’s syndrome
4. Marked loss of weight
5. Backache due to secondary metastasis to vertebral bodies
6. Supraclavicular lymph node enlargement
7. Widespread dissemination
• Sadly, the classic presenting symptoms of dysphagia, regurgitation,
and weight loss are often absent until the primary tumor has become
advanced, and so the tumor is often well-established before the
diagnosis is made.