Dysphagia is difficulty moving food or liquid through the mouth, pharynx, and esophagus. The pt senses swallowed material sticking along the path. Odynophagia is pain on swallowing. Globus pharyngeus is the sensation of a lump lodged in the throat, with swallowing unaffected.
Dysphagia is caused by two main mechanisms: mechanical obstruction or motor dysfunction. Mechanical causes of dysphagia can be luminal (e.g., large food bolus, foreign body), intrinsic to the esophagus (e.g., inflammation, webs and rings, strictures, tumors), or extrinsic to the esophagus (e.g., cervical spondylitis, enlarged thyroid or mediastinal mass, vascular compression). The motor function abnormalities that cause dysphagia may be related to defects in initiating the swallowing reflex (e.g., tongue paralysis, lack of saliva, lesions affecting sensory components of cranial nerves X and XI), disorders of the pharyngeal and esophageal striated muscle (e.g., muscle disorders such as polymyositis and dermatomyositis, neurologic lesions such as myasthenia gravis, polio, or amyotrophic lateral sclerosis), and disorders of the esophageal smooth muscle (e.g., achalasia, scleroderma, myotonic dystrophy).
| APPROACH TO THE PATIENT | ||
DysphagiaHistory can provide a presumptive diagnosis in about 80% of pts. Difficulty only with solids implies mechanical dysphagia. Difficulty with both solids and liquids may occur late in the course of mechanical dysphagia but is an early sign of motor dysphagia. Pts can sometimes pinpoint the site of food sticking. Weight loss out of proportion to the degree of dysphagia may be a sign of underlying malignancy. Hoarseness may be related to involvement of the larynx in the primary disease process (e.g., neuromuscular disorders), neoplastic disruption of the recurrent laryngeal nerve, or laryngitis from gastroesophageal reflux. Physical examination may reveal signs of skeletal muscle, neurologic, or oropharyngeal diseases. Neck examination can reveal masses impinging on the esophagus. Skin changes might suggest the systemic nature of the underlying disease (e.g., scleroderma). Dysphagia is nearly always a symptom of organic disease rather than a functional complaint. If oropharyngeal dysphagia is suspected, video-fluoroscopy of swallowing may be diagnostic. Mechanical dysphagia can be evaluated by barium swallow and esophagogastroscopy with endoscopic biopsy. Barium swallow and esophageal motility studies can show the presence of motor dysphagia. An algorithm outlining an approach to the pt with dysphagia is shown in Fig. 41-1. Approach to the Pt with Dysphagia. |
Pt has difficulty initiating the swallow; food sticks at the level of the suprasternal notch; nasopharyngeal regurgitation and aspiration may be present.
Causes include the following: for solids only, carcinoma, aberrant vessel, congenital or acquired web (Plummer-Vinson syndrome in iron deficiency), cervical osteophyte; for solids and liquids, cricopharyngeal bar (e.g., hypertensive or hypotensive upper esophageal sphincter), Zenker's diverticulum (outpouching in the posterior midline at the intersection of the pharynx and the cricopharyngeus muscle), myasthenia gravis, glucocorticoid myopathy, hyperthyroidism, hypothyroidism, myotonic dystrophy, amyotrophic lateral sclerosis, multiple sclerosis, Parkinson's disease, stroke, bulbar palsy, and pseudobulbar palsy.
Food sticks in the mid or lower sternal area; can be associated with regurgitation, aspiration, odynophagia. Causes include the following: for solids only, lower esophageal ring (Schatzki's ring-symptoms are usually intermittent), peptic stricture (heartburn accompanies this), carcinoma, lye stricture; for solids and liquids, diffuse esophageal spasm (occurs with chest pain and is intermittent), scleroderma (progressive and occurs with heartburn), achalasia (progressive and occurs without heartburn).