Dysphagia
Definition
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Note: I copy the "definition" of something straight from the book. I find it's best to have an all-encompassing definition in order to better orient myself when I am studying.
Show Definition
The terms dysphagia, odynophagia, and globus are defined as follows:
- Dysphagia is a subjective sensation of difficulty or abnormality of swallowing.
- Odynophagia is pain with swallowing.
- Globus sensation is a nonpainful sensation of a lump, tightness, foreign body or retained food bolus in the pharyngeal or cervical area. Globus, on the other hand, is a functional esophageal disorder that is characterized by globus sensation but without an underlying structural abnormality, gastroesophageal reflux disease, or a major esophageal motility disorder.
Incidence/Prevalance
Some estimates suggest 1 in 25 elder adults in USA have it, otherwise generally unclear due to varying etiology and complications that arise.
Higher incidence in females than males, incidence increases with age.
Predisposing factors
It is NOT a sign of normal aging in adults and should be evaluated whenever concerns are present.
Pathogenesis
Acute onset dysphagia is almost always d/t food impaction/foreign body ingestion and should be treated immediately.
Generally divided into oropharyngeal vs. esophageal dysphagia:
(Oropharyngeal Dysphagia - long list, click to open)
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Iatrogenic:
- Medication side effects (chemotherapy, neuroleptics, etc).
- Postsurgical muscular or neurogenic.
- Radiation.
- Corrosive (pill injury, intentional).
-
Infectious:
- Mucositis (herpes, cytomegalovirus, Candida, etc).
- Diphtheria.
- Botulism.
- Lyme Disease.
- Syphillis.
-
Metabolic:
- Amyloidosis.
- Cushing's syndrome.
- Thyrotoxicosis.
- Wilson disease.
-
Myopathic:
- Connective tissue disease (overlap syndrome).
- Dermatomyositis.
- Myasthenia gravis.
- Myotonic dystrophy.
- Oculopharyngeal dystrophy.
- Polymyositis.
- Sarcoidosis.
- Paraneoplastic syndromes.
-
Neurological:
- Brainstem tumors.
- Head trauma.
- Stroke.
- Cerebral palsy.
- Guillain-Barré syndrome.
- Huntington disease.
- Multiple sclerosis.
- Polio.
- Postpolio syndrome.
- Tardive dyskinesia.
- Metabolic encephalopathies.
- Amyotrophic lateral sclerosis.
- Parkinson disease.
- Dementia.
-
Structural:
- Cricopharyngeal bar.
- Zenker's diverticulum.
- Cervical webs.
- Oropharyngeal tumors.
- Osteophytes and skeletal abnormalities.
- Congenital (cleft palate, diverticula, pouches, etc).
(Esophageal Dysphagia - long list, click to open)
-
Intrinsic:
- Benign tumors.
- Caustic esophagitis/stricture.
- Diverticula.
- Malignancy.
- Peptic stricture.
- Eosinophilic esophagitis.
- Infectious esophagitis.
- Pill esophagitis.
- Postsurgery (laryngeal, esophageal, gastric).
- Radiation esophagitis/stricture.
- Rings and webs.
- Lymphocytic esophagitis.
-
Extrinsic:
- Aberrant subclavian artery.
- Cervical osteophytes.
- Enlarged aorta.
- Enlarged left atrium.
- Mediastinal mass (lymphadenopathy, lung cancer, etc).
- Postsurgery (laryngeal, spinal).
-
Motility disorders:
- Achalasia.
- Chagas disease.
- Primary motility disorders.
- Secondary motility disorders.
-
Functional:
Common Findings
-
Oropharyngeal dysphagia:
- Difficulty initiating swallow.
- Cervical region discomfort.
- Swallowing may be accompanied by nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx.
- Oral dysfunction can lead to drooling, food spillage, sialorrhea, piecemeal swallows, and dysarthria.
- Pharyngeal dysfunction can lead to coughing or choking during food consumption, and dysphonia.
-
Esophageal dysphagia:
- Difficulty in swallowing seconds after it is initiated.
- Difficult/sensation of food passaging from lower esophagus to upper stomach.
Other Signs and Symptoms
- Odynophagia.
- Heartburn.
- Weight loss.
- Hematemesis.
- Anemia.
- Regurgitation of food particles.
- Respiratory symptoms.
History
- HPI: Need to know: (1) Solids, liquids, or both? (2) Progressive vs. intermittent (3)
- ROS: Odynophagia may indicate an infectious etiology.
- ALL/MEDS/HIITS: (What are HIITS? - Click to expand) Meds: (Ask specifically about potassium chloride, alendronate, ferrous sulfate, quinidine, ascorbic acid, tetracycline, aspirin and NSAIDs)
- PMH/FAMHx/OBGYN: FamHx GI cancer
- SOCHx: Smoking/EtOH/Recreational drugs
Physical Exam
Coming soon.
Diagnostic Tests
- Initial test is barium esophagram.
- Endoscopy.
- Esophageal manometry.
- Swallow study.
DDx
See pathogenesis section.
Plan
- General: Diet changes, swallowing maneuvers, piecemeal ingestion.
-
Tx/Rx:
- Treat underlying cause, depending on level of neurologic dysfunction, may need enteral feeds.
- Myotomy if achalasia/inability of pharynx to relax. Similarly botulinum toxin injection
Follow-up
Not important.
Consultation/Referral
Not important.
Individual Considerations
Not important.