Dysphagia

Classification & Differentiation

• Oropharyngeal Dysphagia: Difficulty initiating a swallow.
  • Features: Coughing, choking, nasal regurgitation, or aspiration immediately upon swallowing.
  • Etiology: Neuromuscular dysfunction (e.g., stroke, Parkinson disease, Myasthenia Gravis, ALS, Zenker diverticulum).
  • Initial Test: Videofluoroscopic modified barium swallow (MBS). c
• Esophageal Dysphagia: Food feels “stuck” after swallowing (seconds after initiation).
  • Features: Retrosternal food impaction, chest pain.
  • Etiology: Mechanical obstruction or motility disorder.
  • Initial Test: EGD or Barium esophagram (dependent on presentation).

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Diagnostic Algorithm

• Step 1: Determine if Oropharyngeal or Esophageal via Hx.
• Step 2 (If Esophageal): Distinguish Solids vs. Solids & Liquids.
  • Solids only: Mechanical obstruction (luminal narrowing).
    • Progressive: Esophageal cancer (weight loss, age >50) or peptic stricture (longstanding GERD).
    • Intermittent: Schatzki ring (episodic food impaction, “steakhouse syndrome”).
  • Solids & Liquids: Motility/neuromuscular disorder.
    • Progressive: Achalasia (weight loss, regurgitation of undigested food) or systemic sclerosis (acid reflux, Raynaud).
    • Intermittent: Diffuse esophageal spasm (associated w/ chest pain mimicking MI, precipitated by cold liquids).
• Step 3: Select Diagnostic Modality.
  • Alarm symptoms present (weight loss, hematemesis, age >50, iron deficiency anemia) $\to$ EGD (allows biopsy).
  • Prior Hx of radiation, caustic ingestion, complex stricture, or Zenker diverticulum suspected $\to$ Barium esophagram first to prevent iatrogenic perforation.
  • Motility disorder suspected $\to$ Esophageal manometry (gold standard).