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A sensation of difficulty swallowing. Patients typically complain of symptoms seconds after swallowing and identify the suprasternal notch or retrosternal area as the source of their discomfort. Not to be confused with:
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Odynophagia: Pain with swallowing.
Globus sensation: Persistent or intermittent sensation of a lump or foreign body in the throat for >12 weeks that is present even when the patient is not swallowing. Unclear pathogenesis—not due to pathology of esophageal structure, motility, or GERD.
Oropharyngeal dysphagia: Difficulty initiating swallowing. Patients complain of food getting stuck immediately upon swallowing, frequently followed by coughing and choking. Commonly caused by a variety of neurologic disorders (eg, CVA, Parkinson disease).
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Etiologies of dysphagia include (identify most likely based on history):
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Gastroesophageal reflux.
Anatomic abnormalities of the esophagus: Zenker diverticulum, cricopharyngeal bars, peptic strictures, radiation injury, esophageal webs/rings, and esophageal carcinoma.
Esophageal motility disorders:
Achalasia: Inflammatory idiopathic degeneration of neurons in esophageal wall → failure of lower esophageal sphincter (LES) relaxation and distal peristalsis. 2° achalasia or pseudoachalasia is due to Chagas disease, malignancy, or other motor disease. Symptoms are progressive, worsen at night, and usually occur without heartburn (Figure 5.1).
1° motility disorders: A group of disorders with an unclear pathologic or pathophysiologic basis, each characterized by specific manometric findings. Features include diffuse esophageal spasm, nutcracker esophagus, and hypertensive LES. Chest pain is common.
Autoimmune disorders: Scleroderma, Sjögren syndrome (dysphagia is independent of xerostomia but is worsened by it).
Cardiovascular abnormalities: Can lead to dysphagia via compression of the esophagus (eg, vascular rings, aneurysms, left atrial enlargement).
Xerostomia (eg, anticholinergics).
Functional dysphagia: Dysphagia for >12 weeks for 1 year with no identifiable cause.
Esophageal cancer: Progressive dysphagia, weight loss, anemia/heme-positive stools.
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KEY FACT
Dysphagia for only solids suggests a mechanical obstruction (but severe obstruction often progresses to include liquids). Dysphagia equally for solids and liquids suggests a motility disorder.
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Dysphagia warrants immediate workup:
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Esophagogastroduodenoscopy (EGD): Most commonly used for the diagnosis of esophageal dysphagia.
Barium swallow: Less diagnostic but safer than EGD; the initial test of choice for suspected achalasia, revealing classic “bird's beak” narrowing (see Figure 5.1).
Esophageal manometry: Usually performed if the aforementioned studies are ⊝ to evaluate for a 1° esophageal dysmotility disorder. Also, confirmatory for achalasia.
Video fluoroscopic swallow study: Useful in the evaluation of oropharyngeal dysphagia.
Laryngoscopy: Consider in patients with globus sensation to rule out malignancy.
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KEY FACT
Rule out cardiac chest pain in a patient suspected of having a 1° esophageal dysmotility ...