Patient history and physical examination
A good clinical history and physical exam are critical when evaluating all patients with dysphagia. Along with the timing and location of the dysphagia, it is important to elicit: (i) the type of food (solid or liquid) that produces symptoms; (ii) the frequency of symptoms (if symptoms are consistent, progressive, or intermittent); (iii) the onset of symptoms (acute or gradual over time); (iv) the duration of symptoms; and (v) the presence of any associated symptoms such as weight loss, regurgitation, or oropharyngeal symptoms. Taking a thorough medication history is essential, as medications such as nonsteroidal anti‐inflammatories (NSAIDs), potassium supplementation, vitamins, and bisphosphonates are all well‐known to cause pill esophagitis [17]. In patients with suspected eosinophilic esophagitis, it is also important to ask about a history of asthma, eczema, or any known food or environmental allergies. A short duration of symptoms, in the setting of significant weight loss, is suggestive of a malignant etiology.
When obtaining a patient history, it is important to remember that patients with chronic conditions often develop compensatory strategies and techniques to help ease their symptoms. This is often the case for patients with dysphagia. Patients may avoid their most troublesome foods, eat more slowly or consistently be the last person to finish a meal, or dunk solids into liquids to moisten them prior to swallowing. Some patients may report that they do not have any difficulty swallowing, but a more detailed dietary history will reveal that they are avoiding entire groups of foods. In addition, some patients may avoid social situations such as family meals or meals with colleagues at work, due to embarrassment at their symptoms. Often, accompanying family members help to provide key portions of a patient’s history, as the patient may have consciously or subconsciously adapted to their symptoms [18].
While often unremarkable, a good physical exam is important in all patients with dysphagia, especially those with suspected oropharyngeal dysphagia. A neurologic exam, including an examination of the cranial nerves, should be performed to evaluate for potential underlying neurologic etiologies. This includes assessing for any asymmetry, dysarthria, tongue fasciculation, tremor, and cognitive dysfunction. An oral exam is important to assess for poor dentition or if a patient is edentulous, as well as for buccal lesions, which may suggest lichen planus. The neck should be palpated for lymphadenopathy and an enlarged thyroid. Patients should also be examined for calcinosis, Raynaud’s phenomenon, sclerodactyly (thickness or tightness of the skin), and telangiectasias, which will suggest CREST syndrome and concomitant esophageal dysmotility.
Esophageal dysphagia
Esophageal dysphagia is due to either a structural/mechanical obstruction or abnormal esophageal motility. Obstructive etiologies can be (i) benign or malignant, (ii) intrinsic or extrinsic, (iii) distal or proximal, and (iv) mucosal or intramural. Common mechanical causes of dysphagia are reflux‐induced strictures, rings, webs, esophageal or head and neck malignancy, or large hiatal or paraesophageal hernias. Inflammatory diseases such as eosinophilic esophagitis and lichen planus often present with luminal narrowing consistent with an obstructive phenotype. A rare but well‐described cause of long‐standing dysphagia is dysphagia lusoria, or extrinsic compression on the esophagus by an aberrant right subclavian artery. Patients with an anatomic cause of dysphagia typically have symptoms upon ingestion of solids and not liquids, and more likely with larger solids of a denser consistency. If the obstruction worsens and causes severe luminal narrowing, patients may develop dysphagia for both solids and liquids.
Patients with motility disorders often have dysphagia for both solids and liquids that progresses over time. Persistent, uninterrupted symptoms suggest peristaltic dysfunction such as in achalasia or systemic sclerosis, while intermittent symptoms may suggest esophageal spasm or ineffective motility. For patients with persistent symptoms suspected of having a motility disorder, associated symptoms often help in pointing toward a diagnosis. Achalasia patients often have associated regurgitation of undigested food, while patients with systemic sclerosis frequently have severe heartburn and, non‐uncommonly, reflux‐related distal esophageal strictures. For patients with intermittent symptoms, associated chest pain supports a diagnosis of esophageal spasm or jackhammer esophagus. This is usually absent in patients with ineffective esophageal motility. An algorithm for the evaluation of dysphagia is shown in Figure 1.1.
Diagnostic approach
In many patients with dysphagia, no single test is used to make a diagnosis, as endoscopy, radiography, and manometry are often used in a complementary manner [19]. While a barium esophagram has traditionally been the initial test used to evaluate dysphagia, most patients now proceed directly to an upper endoscopy [20]. Endoscopy not only allows for detailed anatomic and mucosal evaluations but also serves as both a diagnostic and therapeutic study, as the physician can take biopsies and dilate the esophagus in the same session. A barium esophagram allows for greater evaluation of potential motility disorders, as well as anatomic abnormalities such as a large hiatal or paraesophageal hernia. As compared to endoscopy, a barium esophagram is also more sensitive for the detection of esophageal strictures [21, 22], and the use of a 13 mm barium tablet can detect subtle strictures that may not be appreciated at the time of endoscopy [23]. A pre‐endoscopy barium esophagram can also allow the physician to plan the endoscopy, as the finding of a tight stricture may determine the type of dilation required, or a diagnosis of achalasia may prompt a pneumatic dilation or the injection of botulinum toxin at the time of the procedure [18].
Figure 1.1 Algorithm for the evaluation of dysphagia.
Source: Madanick RD, Shaheen NJ. Symptom overview and quality of life. In: Castell DO, Richter JE, eds. The Esophagus, 4th edn.Lippinicott Williams and Wilkins, 3–13. © 2004, Wolters Kluwer.
High‐resolution esophageal manometry should be performed in patients who have an unrevealing upper endoscopy and in patients in whom a motility disorder is strongly suspected. In patients with suspected oropharyngeal dysphagia, the modified barium swallow is the test of choice, as this allows for assessment of aspiration and muscular strength and coordination, along with the opportunity to trial foods of different consistencies in an effort to replicate patient symptoms [18]. Working with a speech pathologist, a patient may also start to implement directed therapy based on the results of the study.
Odynophagia
The word odynophagia comes from the Greek words odyno (pain) and phagia (to eat) and is pain upon swallowing. The pain is usually felt in the mouth, throat, or chest and is most often described as an aching, burning, or, in some instances, sharp stabbing pain. Pain may or may not occur with concomitant difficulty swallowing. The presence of odynophagia suggests an esophageal mucosal injury, often due to pill‐induced or infectious esophagitis.
Table 1.4 Common etiologies of pill esophagitis.
| Nonsteroidal anti‐inflammatory medications (NSAIDs) Aspirin Potassium chloride (KCl) Bisphosphonates Quinidine Iron compounds AntibioticsTetracycline/DoxycyclineClindamycin |
The most common medications implicated in pill‐induced esophagitis are listed in Table