Heartburn, dysphagia, and odynophagia almost always indicate a primary esophageal disorder.
Heartburn (pyrosis) is the feeling of substernal burning, often radiating to the neck. Caused by the reflux of acidic (or, rarely, alkaline) material into the esophagus, it is highly specific for GERD.
Difficulties in swallowing may arise from problems in transferring the food bolus from the oropharynx to the upper esophagus (oropharyngeal dysphagia) or from impaired transport of the bolus through the body of the esophagus (esophageal dysphagia). The history usually leads to the correct diagnosis.
1. Oropharyngeal dysphagia
The oropharyngeal phase of swallowing is a complex process requiring elevation of the tongue, closure of the nasopharynx, relaxation of the upper esophageal sphincter, closure of the airway, and pharyngeal peristalsis. A variety of mechanical and neuromuscular conditions can disrupt this process (Table 15–8). Problems with the oral phase of swallowing cause drooling or spillage of food from the mouth, inability to chew or initiate swallowing, or dry mouth. Pharyngeal dysphagia is characterized by an immediate sense of the bolus catching in the neck, the need to swallow repeatedly to clear food from the pharynx, or coughing or choking during meals. There may be associated dysphonia, dysarthria, or other neurologic symptoms.
Table 15–8.Causes of oropharyngeal dysphagia. ||Download (.pdf) Table 15–8. Causes of oropharyngeal dysphagia.
Brainstem cerebrovascular accident, mass lesion
Amyotrophic lateral sclerosis, multiple sclerosis, pseudobulbar palsy, post-polio syndrome, Guillain-Barré syndrome
Parkinson disease, Huntington disease, dementia
Muscular and rheumatologic disorders
Thyrotoxicosis, amyloidosis, Cushing disease, Wilson disease
Medication side effects: anticholinergics, phenothiazines
Polio, diphtheria, botulism, Lyme disease, syphilis, mucositis (Candida, herpes)
Cervical osteophytes, cricopharyngeal bar, proximal esophageal webs
Postsurgical or radiation changes
Upper esophageal sphincter dysfunction
Esophageal dysphagia may be caused by mechanical obstructions of the esophagus or by motility disorders (Table 15–9). Patients with mechanical obstruction experience dysphagia, primarily for solids. This is recurrent, predictable, and, if the lesion progresses, will worsen as the lumen narrows. Patients with motility disorders have dysphagia for both solids and liquids. It is episodic, unpredictable, and can be progressive.
Table 15–9.Causes of esophageal dysphagia. ||Download (.pdf) Table 15–9. Causes of esophageal dysphagia.
|Cause ||Clues |
|Mechanical obstruction ||Solid foods worse than liquids |
|Schatzki ring ||Intermittent dysphagia; not progressive |
|Peptic stricture ||Chronic heartburn; progressive dysphagia |
|Esophageal cancer ||Progressive dysphagia; age over 50 years |
|Eosinophilic esophagitis ||Young adults; small-caliber lumen, proximal stricture, corrugated rings, or white papules |
|Motility disorder ||Solid and liquid foods |
|Achalasia ||Progressive dysphagia |
|Diffuse esophageal spasm ||Intermittent; not progressive; may have chest pain |
|Scleroderma ||Chronic heartburn; Raynaud phenomenon |
|Ineffective esophageal motility ||Intermittent; not progressive; commonly associated with GERD |
Odynophagia is sharp substernal pain on swallowing that may limit oral intake. It usually reflects severe erosive disease. It is most commonly associated with infectious esophagitis due to Candida, herpesviruses, or CMV, especially in immunocompromised patients. It may also be caused by corrosive injury due to caustic ingestions and by pill-induced ulcers.