Oropharyngeal and Esophageal Causes of Dysphagia - Differential Diagnosis
Oropharyngeal Dysphagia
• Neuromuscular causes: CVA/CNS tumor/ALS, Parkinson's, Myasthenia gravis/Lambert Eaton, Muscular dystrophy
• Structural causes:
- Intrinsic compression: Zenker's diverticulum, cervical ring/web/stricture, luminal malignancy
- Extrinsic compression: Head/Neck Malignancy, Anterior mediastinal mass (4 T's), Goiter
Esophageal Dysphagia
• Neuromuscular causes:
- Non-relaxation of EG junction: Achalasia, EG junction outflow obstruction
- Abnormal peristalsis: Absent Contractility, Ineffective Esophageal Motility, Fragmented Peristalsis, Esophageal Spasm, Hypercontractile Esophagus
- Systemic sclerosis
- Functional dysphagia
• Structural causes:
- Intrinsic compression: Schatzki Ring, Plummer-Vinson Web, Strictures from esophagitis (GERD, pills, eosinophils, infections), Luminal malignancy
- Extrinsic compression: Vascular ring, anterior mediastinal mass, enlarged aorta/heart
Dr. Anthony Xu @AnthonyXuMD
#Oropharyngeal #Esophageal #Dysphagia #Differential #Diagnosis #causes #gastroenterology
Dysphagia - Differential Diagnosis Algorithm
Oropharyngeal Dysphagia
Esophageal Dysphagia
• Upper 2/3 (striated muscle): stroke, NMJ disorders, ALS, MS, muscular dystrophy, spinal muscular atrophy, SLE, Sjogren, web
• Mid esophagus: pill esophagitis
• Lower 2/3 (smooth muscle): scleroderma, MCTD, achalasia. strictures, adenocarcinoma, DES, schatzki
Entire length: RA. inflammatory myopathies
Matthew Ho, MD PhD @MatthewHoMD
#Dysphagia #Differential #Diagnosis #Algorithm #Oropharyngeal #Esophageal #gastroenterology
Dysphagia - Differential Diagnosis Framework
Symptom | Diagnosis
• Solid-food dysphagia present for months to years | Mechanical obstruction: Esophageal web or a distal esophageal ring (Schatzki ring)
• Progressively increasing solid-food dysphagia | Esophageal: Peptic stricture, ring, web or carcinoma. Extrinsic to esophagus: Mediastinal mass, Left atrial size increase
• Solid food and liquid or liquid-only dysphagia | Esophageal motility disorder such as achalasia. Intermittent: Diffuse esophageal spasm
Oropharyngeal Dysphagia ("Transfer dysphagia"):
Difficulty initiating swallowing
• Coughing
• Choking
• Nasal regurgitation of fluids
• Muscular or neurologic disorders, most commonly stroke, Parkinson disease. Other - ALS, Dementia
• Structural - Zenker's, Cervical osteophytes, malignancy
Risk for aspiration pneumonia
Videofluoroscopy is used to evaluate suspected oropharyngeal dysphagia.
Barium swallow is also considered.
Esophageal Dysphagia:
• Can initiate the swallowing process but often feel chest discomfort
• Due to a mechanical obstruction or a motility disorder
• Food “sticking” or discomfort in the retrosternal region
• Bolus slow to go down or “sitting” in the chest
• Mechanical obstruction or a motility disorder
URGENT WORKUP:
• Complete obstruction
• Hematemesis
• Odynophagia
• Onset in an older patient
• Dysphagia associated with weight loss or acute course
Oropharyngeal Dysphagia: Testing
• Videofluoroscopy is used to evaluate suspected oropharyngeal dysphagia
• Barium swallow is also considered
Esophageal Dysphagia: Testing
• Suspected esophageal motility disorder → manometry
• Suspected structural disorder → EGD
Treatment
• Oropharyngeal dysphagia is managed with dietary adjustment and speech therapy.
• Therapy for esophageal dysphagia is dictated by the underlying cause.
#Dysphagia #Differential #Diagnosis #Management #gastroenterology #workup
Achalasia Summary
Epidemiology: 10 cases per 100,000 individuals
Defined by inadequate relaxation of the LES and aperistalsis
Primary or idiopathic achalasia cause is unknown.
Secondary achalasia is due to diseases that cause esophageal motor abnormalities.
Achalasia has an insidious onset, and disease progression is gradual.
Causes:
• Idiopathic
• Viral
• Autoimmune
• Neurodegenerative disorders
• Infection (Chagas disease)
Clinical Presentation:
• Dysphagia of both solids and liquids
• Regurgitation of undigested food or saliva
• Chest pain
• Hiccups
• Globus sensation
Achalasia: Testing
The diagnosis of achalasia is established by the presence of aperistalsis in the distal two-thirds of the esophagus and incomplete lower esophageal sphincter (LES) relaxation on manometry.
High-resolution esophageal manometry:
• Absence of peristalsis
• Failure of lower esophageal sphincter to relax
EGD:
• Exclude gastroesophageal junction adenocarcinoma
Barium swallow:
• “Bird’s beak” narrowing of the gastroesophageal junction
• Useful if manometry unclear
DDX:
1. GERD
2. Pseudoachalasia
3. Other esophageal motility disorders:
• Distal esophageal spasm
• Jackhammer esophagus
Pseudoachalasia:
Malignant tumor infiltration or other secondary causes leading to myenteric plexus damage and can present similarly to achalasia. Pseudoachalasia has been associated with sudden weight loss later in life.
Three clinical features suggest cancer as a cause of pseudoachalasia:
• Short duration of dysphagia (<1 year)
• Weight loss (>6.8 kg)
• Age older than 55 years
Suspected pseudoachalasia should be evaluated with CT, endoscopy, or endoscopic ultrasonography.
Treatment:
Laparoscopic myotomy of the LES is the first-line therapy for achalasia.
Treatment options include:
• Mechanical disruption of the muscle fibers of the LES (eg, pneumatic dilation, laparoscopic Heller myotomy, or peroral endoscopic myotomy [POEM])
• Or Biochemical reduction in LES pressure (eg, injection of botulinum toxin, use of oral nitrates)
#Achalasia #diagnosis #management #treatment #gastroenterology #esophageal #esophagus
Algorithm for the Evaluation of Dysphagia:Oropharyngeal:
- Characterized by difficulty initiating swallowing and accompanied by choking/coughing, nasopharyngeal regurgitation or aspiration.
- Involved anatomy: Tongue, muscles of mastication, soft palate (elevation to close nasopharynx), suprahyoid muscles (elevate larynx), epiglottis (occlude airway), cricopharyngeus muscle (release upper esophageal sphincter). Neurological control predominantly coordinated by cranial nerves (V, VII, IX, X, XII)
Esophageal:
- Delayed after initiating swallowing and characterized by a sensation of food bolus arresting in transit.
Involved anatomy: Skeletal and smooth muscle along the esophagus and lower esophageal sphincter. Neurological control predominantly coordinated by medulla #Diagnosis #Differential #EM #GI #Dysphagia #Oropharyngeal #Esophageal #Neuromuscular #Anatomic #Intraluminal #Extraluminal #Algorithm #Differential #Ddxof
