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.
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