Heartburn, dysphagia, and odynophagia almost always indicate a primary esophageal disorder.
Heartburn (pyrosis) is the feeling of substernal burning, often radiating to the neck. Most commonly caused by the reflux of acidic (or, rarely, alkaline) material into the esophagus, heartburn is highly suggestive of GERD.
Dysphagia is defined as difficulty swallowing food or liquid due to the sensation of it sticking in the throat or chest, with a discomfort, or a choking sensation. In a 2020 survey of US adults, 15% of adults reported recent dysphagia that required compensatory maneuvers (avoiding certain foods or cutting into smaller pieces; eating more slowly; drinking liquids). Up to one-half of these adults previously had sought evaluation for their symptoms. 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 suggests 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 17–8). 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 17–8.Causes of oropharyngeal dysphagia. ||Download (.pdf) Table 17–8. 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 17–9). 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.