Dysphagia

The authors enumerate oropharyngeal, esophageal, and structural causes of swallowing difficulty and outline a diagnostic approach, pointing out "red flags" and special considerations along the way.

By Nasir Hussain, MD, and Bernard Karnath, MD

What is the definition of dysphagia?

The word dysphagia is derived from the Greek roots dys (with difficulty) and phagia (to eat) and is defined as the subjective sensation of having difficulty swallowing. The feeling of food being stuck in the throat or chest and difficulty initiating a swallow are some of the ways patients describe the feeling. These patients may have a change in voice or a globus or ball-like sensation in the hypopharynx; they may also experience difficulty masticating, coughing while eating, and weight loss and are susceptible to aspiration pneumonia. Odynophagia is pain on swallowing and may be associated with dysphagia.
 

How common is dysphagia? Does the incidence change with age?

In a U.S. household survey, 7% of respondents reported that they had experienced dysphagia at some point in their lives. Approximately 2% of otherwise healthy adults over age 65 are reported to have dysphagia; the incidence increases to 12% to 13% in the hospitalized elderly. It has been reported that 50% to 60% of patients in nursing homes have dysphagia.
 

What are the causes of oropharyngeal dysphagia?

Neurogenic causes of oropharyngeal dysphagia include disorders such as Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis, and myasthenia gravis. Brain-stem strokes, trauma, tumors, and infections can cause dysphagia by affecting the cranial nerves involved in swallowing. Cortical strokes due to hemorrhage or thromboembolism usually cause dysphagia due to the loss of upper motor neuron influence on the nuclei of the cranial nerves involved in swallowing.

Dysphagia due to involvement of the striated muscles of the oropharynx may be present in approximately 25% of patients with inflammatory myopathies such as polymyositis, dermatomyositis, and sarcoid myopathies. Muscular dystrophies are a rare cause of dysphagia that can occur in adults, especially the elderly. Oropharyngeal dysphagia may also be present as a result of complications of brain-stem, oral, pharyngeal, and laryngeal surgery. Sometimes carotid endarterectomy and cervical spine surgeries are complicated by nerve injury that can cause dysphagia. Drugs affecting cognition, such as central nervous system (CNS) depressants, and drugs that cause myopathy, such as corticosteroids, may also cause dysphagia, which usually resolves after the medication is stopped.

Oropharyngeal cancers may manifest as dysphagia and should be suspected in high-risk patients. Psychogenic dysphagia presents with oral apraxia but normal speech and pharyngeal function. Neurologic evaluation is also normal. Associated clinical symptoms of anxiety, depression, or other psychiatric illness may provide important clues to a psychogenic etiology. Psychogenic dysphagia is a diagnosis of exclusion.
 

What are some of the esophageal etiologies of dysphagia?

Patients with esophageal dysphagia generally complain that food feels as if it were stuck in their chest after it is swallowed. Food sticking at the xiphoid process level may suggest lower esophageal disorders, including esophagitis, stricture, and malignancy. However, a patient's pointing to or otherwise indicating where the food seems to be sticking is not always reliable in predicting the actual anatomical site of an obstruction. When patients have difficulty swallowing solids only, a mechanical cause of an obstruction should be suspected, although patients with advanced cases of dysphagia due to a mechanical cause may also have problems swallowing liquids.

Patients with progressive symptoms and a history of chronic heartburn may have esophagitis from acid reflux. Barrett's esophagus and peptic stricture of the lower esophagus are long-term complications of gastroesophageal reflux disease (GERD). Barrett's esophagus increases the risk for esophageal cancer, and a history of weight loss in such a patient should prompt a workup to rule out cancer.

Infectious esophagitis is most commonly found in immunocompromised patients, particularly those with a history of HIV infection. It may have bacterial, fungal, viral, or parasitic causes. Oral thrush in a dysphagic patient may be an important clue to esophageal candidiasis. Esophageal stasis due to stricture or achalasia may be an underlying predisposing cause for infectious esophagitis in up to 25% of patients.

Pill-induced esophagitis results from injury secondary to a retained pill. Enteric-coated nonsteroidal anti-inflammatory drugs (NSAIDs) are a common cause. Other implicated drugs include iron pills, potassium tablets, quinidine, and vitamins. Patients should take pills with a lot of water at least two hours before bedtime.
 

Are there other causes of dysphagia involving the esophagus?

Dysphagia may also be due to neuromuscular or motility disorders of the esophagus. Diffuse esophageal spasm (DES), for example, is a motility disorder that affects the smooth muscle of the esophagus. Patients with DES present with chest pain, dysphagia, and occasionally regurgitation. Barium studies are usually normal above the level of the aorta but show a spiral or corkscrew appearance to the esophagus below that level. Manometric studies show multiple spontaneous contractions with a large amplitude. After coronary artery disease has been ruled out, the diagnosis of DES is made in a symptomatic patient with consistent radiologic and manometric studies. Nitrates and calcium channel blockers are used to treat this disorder.

Achalasia is a neuromuscular disorder in which there is degeneration of esophageal ganglion cells in the Auerbach plexus. This results in an inability of the lower esophageal sphincter to relax, causing an increase in intraluminal pressure. Symptoms are similar to DES.

Patients with scleroderma may have dysphagia as a result of diminished or absent peristalsis in the lower esophagus and an incompetent lower esophageal sphincter. Contrast studies also show dilatation of the esophagus. These patients are predisposed to reflux, Barrett's esophagus, and esophageal cancer.

Esophageal dysphagia may also result from failure of the cricopharyngeal muscle, which serves as a functional upper esophageal sphincter, to relax. The most common cause is a cerebrovascular accident.

Nonspecific esophageal motor disorder is seen with aging and in patients with diabetes. Radiologic studies show abnormal peristalsis and nonperistaltic contractions.
 

Are there structural disorders that can cause dysphagia?

Several structural disorders can result in what is commonly known as mechanical dysphagia. Zenker's diverticulum is a pharyngeal diverticulum proximal to the cricopharyngeal muscle. Symptoms consist of regurgitation of saliva and food, coughing and aspiration occurring minutes to hours after eating, and halitosis. Diagnosis is confirmed by barium swallow studies. Treatment is surgical, with or without endoscopy. There is excellent relief of symptoms if a cricopharyngeal myotomy is also performed.

A common cause of esophageal dysphagia is Schatzki's rings in the lower esophagus, which are usually related to reflux. A biopsy should be done to exclude malignancy and dilatation to relieve symptoms. Plummer-Vinson syndrome is characterized by an esophageal web in the hypopharynx and iron deficiency anemia. Strictures, whether benign or malignant, become symptomatic when there is narrowing of the esophageal lumen by 50% or more. Initially, patients have dysphagia with solid foods only, but as the disease progresses, particularly with malignant causes, dysphagia with liquids too also develops. Benign esophageal stricture can be webs or rings and can be symptomatic. External compression of the esophagus due to mediastinal tumors or vascular compression can also be the cause of dysphagia. The term dysphagia lusoria is used to describe dysphagia resulting from any type of vascular ring. These are malformations of the aortic arch that entrap the esophagus partially or completely. This is a rare cause of dysphagia in adults.
 

Does the differential diagnosis change in elderly patients with dysphagia?

Many elderly people take a lot of different medications. As a result, there is a higher incidence of pill-induced esophagitis and dysphagia in this age group. While many drugs can cause esophagitis, most cases are due to only a few medications. Prescription and nonprescription NSAIDs top the list. Alendronate, an oral treatment for osteoporosis, is sometimes associated with severe esophagitis. Distal esophageal ulcers and strictures are commonly linked to potassium chloride and quinidine tablets. Tetracycline and doxycycline can cause small ulcers in the mid-esophagus.

Motility disorders of the esophagus, decreased salivary flow, and distorted anatomy predispose the elderly to pill-induced esophagitis. Large pill size and sustained-release pills, especially when taken in the supine position with only a small amount of liquid, further increase this risk.

Most cases of pill-induced esophagitis resolve after the offending agent is stopped, and no other therapy may be needed. Sucralfate may speed up the healing process and acid-suppressive therapy may be used if concomitant GERD is suspected. Minimizing the number of medications being taken, taking medications two hours before bedtime, taking medications with an adequate amount of fluid, and staying upright 30 minutes after taking medications are important preventive measures.

Presbyesophagus or nonspecific esophageal motor disorder is an important differential diagnosis for dysphagia and chest pain in the elderly. Achalasia becomes more prevalent with old age and should be considered in the diagnostic workup of dysphagia in the elderly.

Strokes and other CNS disorders are more common in the elderly and should always be considered in the differential diagnosis.
 

What are some "red flags" in the clinical presentation of dysphagia?

Is the dysphagia getting worse? Has there been weight loss over the past several months? Has there been long-term use of alcohol or tobacco? Has there been a long history of gastroesophageal reflux? These are useful questions in determining the potential diagnosis of esophageal neoplasm. Both squamous cell carcinoma and adenocarcinoma of the esophagus tend to present with progressive dysphagia and associated weight loss. Squamous cell carcinoma is associated with long-term use of alcohol or tobacco, while adenocarcinoma is associated with a long history of gastroesophageal reflux associated with Barrett's esophagus.
 

What are the initial diagnostic steps in evaluating a patient with dysphagia?

The first step is to obtain a good history. The duration and progression of symptoms, as well as the effect of different food consistencies, will help in sorting out the differential diagnosis. Are the symptoms intermittent or progressive? Are there associated symptoms such as heartburn or chest pain? Are there any neuromuscular symptoms such as diplopia, facial muscle weakness, or weakness of other muscles? Is there a voice change?

The clinician should attempt to distinguish oropharyngeal from esophageal dysphagia. In addition to the symptoms noted earlier, patients with oropharyngeal dysphagia may have associated otalgia or dysphonia. Esophageal dysphagia may present with the feeling of food being stuck or hung up in the lower throat, retrosternal area, or epigastrium. These patients may also complain of regurgitating food and may have symptoms or complications of aspiration. The history should also include questions to assess for risk factors that may cause dysphagia, such as a history of tobacco or alcohol use or medical problems such as stroke, diabetes, and HIV infection. A medication history is obviously important to rule out pill-induced esophagitis and dysphagia. A family history of a neuromuscular disorder might provide a clue to the cause of dysphagia.

A detailed physical examination of the oral mucosa, tongue, palate, and throat is important. Patients should be tested for a gag reflex, movement of the soft palate, and tongue movement. The amount of salivary secretions should be estimated; decreased secretions may indicate Sjögren's syndrome. The examination might also turn up clues suggesting systemic sclerosis, systemic lupus erythematosus, or other rheumatic diseases. A detailed neurologic and muscular examination will also help in the differential diagnosis.
 

Of what value are x-rays in the workup of the patient with dysphagia?

Plain x-rays of the chest are of limited value in the workup of a dysphagic patient, although they may sometimes show an air-fluid level in the chest in the presence of a lower esophageal obstruction. Barium studies of the pharynx, esophagus, and stomach should be performed during the initial workup. These studies can help identify intrinsic lesions (such as esophageal webs and rings), obstructing mass lesions, extrinsic compression from a retrosternal goiter, and other causes. Air contrast studies help provide mucosal details, including the lining of the gastric cardia; tumors in that region may cause dysphagia. Sometimes a bolus challenge test using a barium-coated tablet or meal may help identify early obstruction due to a web or stricture.

Radiologic studies can be complemented with videofluoroscopy, which allows for the replaying and slow-motion evaluation of the oropharyngeal phase of swallowing.
 

What additional tests can be done to establish the diagnosis of dysphagia?

Endoscopy is preferred in acute dysphagia that occurs during eating, which may be due to a piece of bone being stuck in the esophagus. When infections or superficial erosions are suspected, endoscopy may have an advantage over barium studies because it can visualize lesions that may not be detected by radiologic studies. Endoscopy is indicated whenever an abnormality is found on radiologic studies.

Esophageal manometry can be used to assess peristaltic function of the esophagus. It is most helpful in establishing a diagnosis of achalasia or diffuse esophageal spasm in patients with dysphagia who have been evaluated with a barium study. Manometric features exhibited by achalasia include the absence of peristalsis, with incomplete relaxation of the lower esophageal sphincter. Diffuse esophageal spasms would show numerous simultaneous contractions.

Esophageal pH monitoring is the best study for confirming acid reflux. Chronic acid reflux can lead to peptic strictures. In this procedure, a small pH probe is placed just above the lower esophageal sphincter. The probe is attached to a portable recording device for 24 hours. It is useful in evaluating patients with a normal endoscopic study who have reflux symptoms or atypical symptoms of reflux such as chronic cough, asthma, and laryngitis.
 

What are the treatment options for dysphagia?

The treatment options for dysphagia depend largely on the etiology. Dilatation can be used for conditions such as peptic stricture, Schatzki's rings, and achalasia. Antireflux precautions should also be instituted, along with medical therapy with proton pump inhibitors or H₂ receptor antagonists. For patients with motility disorders, a modification of dietary habits is helpful. Patients should be instructed to eat more slowly, to eat smaller portions of food, and to avoid very hot or very cold liquids. If these conservative measures fail, calcium channel blockers or nitrates may be tried. For patients with esophageal cancer, surgical resection is the only curative option. Palliative therapies include placement of an esophageal expandable stent.
 

Does the use of a feeding tube improve outcomes in elderly patients with dysphagia?

Tube feedings can be performed via a nasogastric tube or a gastrostomy. A common scenario in the elderly population is dysphagia associated with acute brain-stem infarct. A randomized prospective trial comparing percutaneous endoscopic gastrostomy versus nasogastric tube feedings after acute dysphagic stroke found gastrostomy tube feedings to be superior. Patients fed via a gastrostomy tube showed greater improvement in nutritional status and had significantly lower mortality rates.

Another common scenario in the elderly population is a failure to thrive as a result of severe dementia. Such patients frequently present with poor nutritional status and weight loss, and enteral tube feedings are frequently used in this setting. However, no published randomized trials have been able to demonstrate an improvement in clinical outcomes, including prolonged survival.
 

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