Dr. Jack Keegan treated us today to a phenomenal noon report on inflammatory myopathies. As part of this interesting case, he discussed pearls about the workup of dysphagia.
Here are some key learning points from Dr. Keegan:
Dysphagia is defined as "the awareness of food not passing during the swallowing process". Recall that there are two distinct steps when swallowing:
Food bolus moves from mouth to hypopharynx & upper esophagus (oropharyngeal process).
Food bolus moves through esophagus into stomach (esophageal process).
Approach a new patient with dysphagia as follows:
1. Determine if it is an oropharyngeal problem or an esophageal problem.
Oropharyngeal Dysphagia
This is also known as "transfer dysphagia". These patients have difficulty initiating the swallow. Symptoms occur within one second of starting the swallowing process.
You may see:
Drooling
Nasopharyngeal aspiration
Choking
The initial test of choice for evaluation of oropharyngeal dsyphagia is a modified barium swallow (i.e. videofluoroscopy). This starts with a liquid phase, followed by a solid phase if the initial liquid testing is non-diagnostic. If the results of this test are normal, you have excluded oropharyngeal dysphagia and you should proceed to evaluate for esophageal dysphagia.
Esophageal Dysphagia
These patients have difficulty seconds after initiating the swallow. They can complain of food "getting stuck" or lower sternal discomfort.
Diagnosis of esophageal dysphagia centers on upper endoscopy, as this is both diagnostic and can be therapeutic.
2. If the patient has esophageal dysphagia, determine if the patient has dysphagia to solids, liquids, or both.
Dysphagia to solids should prompt you to think of an anatomical problem:
Stricture
Webs
Rings
Cancer
Eosinophilic esophagitis
Dysphagia to both solids and liquids should make you think of a motility problem:
Achalasia
DES
Scleroderma
Sjogren's
References:
1. MKSAP 17. "Dysphagia".
2. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013 Mar;108(3):308-28.
3. Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol. 2013 Aug;108(8):1238-49.
4. Fass, R. "Approach to the evaluation of dysphagia in adults" from UptoDate. 2019.