Current Approach to

Dysphagia

Ronnie Fass, MD

Professor of Medicine

Case Western Reserve University

Physiology of Swallowing:

Oral Phase Pharyngeal Phase

Pharyngeal and Esophageal Phase:

Physiology of Swallowing:

Dysphagia in Greek

Dys = with difficulty

Phagia = to eat

Prevalence of Dysphagia

• General population – 7%

• Middle age – 1.6 – 15%

• Elderly - 13 – 35%

• Patients with head injury, CVA or

neurologic disorders – 20 – 60%

Trate et al. Prim Care 1996;23:417.

Lindgren et al. Dysphagia 1991;6:187.

Acute Dysphagia (“Steakhouse Syndrome”)

• Usually requires an immediate intervention

• Commonly associated with food impaction (meat!)

(beef > pork > turkey > chicken > fish)

• Usually indicative of mechanical obstruction

• More common in the elderly ( chewing)

• Dramatic presentation

• Most common causes:

– Schatzki’s ring

– Eosinophilic esophagitis

Eosinophilic Esophagitis (EoE)

“Eosinophilic esophagitis represents a

chronic, immune / antigen mediated,

esophageal disease characterized

clinically by symptoms related to

esophageal dysfunction and histologically by

eosinophil-predominant inflammation.”

Liacouras C et al, J Allergy Clin Immunol 2011

2011 Updated Consensus Report

• EoE is a clinico-pathologic disease

• Clinically characterized by esophageal dysfunction

• Pathologically 1 or more biopsies show eosinophil

predominant inflammation (15+ eos in peak hpf)

• Histopathology is isolated to esophagus

• Other causes need to be excluded

• “PPI responsive esophageal eosinophilia” • Diagnosis made by clinicians

• Rarely < 15 eos/hpf (if other clinicopathologic

features present)

Liacouras C et al, J Allergy Clin Immunol 2011

Eosinophilic Esophagitis

Remedios et al. Gastrointest Endosc 2006; 63:3-12

Oropharyngeal Dysphagia

• Source

– Oropharynx & upper esophageal sphincter

– Abnormal bolus transfer to the esophagus

• Symptoms

– Food getting stuck immediately after

swallowing

– Choking, coughing and nasal regurgitation

– Location – cervical region

– Only one manifestation of the primary

disease (e.g., stroke)

Esophageal Dysphagia

• Source

– Body of esophagus, LES and cardia

– Abnormal bolus transport through the esophagus

• Causes

– Mechanical or functional

• Symptoms

– Onset of symptoms: several seconds after initiating

a swallow

– Difficulties swallowing (food is getting stuck) of

solids and/or liquids

• Location – cervical, sternal

Taking History From A

Patients With Dysphagia

• Do liquids, solids or both elicit dysphagia?

• What is the course of dysphagia?

• What is the duration of dysphagia?

• Can the patient localize the dysphagia?

• Does the patient have comorbidities?

• What medication does the patient take?

• Is the dysphagia associated with

odynophagia, anorexia and weight loss?

Review of Systems

• Ask about common systemic processes

associated with dysphagia:

– Tobacco/Alcohol

– Medications – antihistamines,

anticholinergics, antidepressants,

antihypertensives

– Osteoarthritis

– Systemic neuromuscular disorders

– Auto-Immune disorders

– Psychiatric state

Physical Exam

• General: body habitus, mental status, drooling,

wheezing, dyspnea, voice quality

• Cranial nerves

• Inspection of the tongue and palate for

strength/symmetry

• Laryngeal examination: pooled secretions,

vocal fold movement, interarytenoid area

Esophageal Dysphagia – An

Alarm Symptom

First test – An upper endoscopy

Barium Swallow - Post-laryngectomy,

caustic ingestion and radiation

Mechanistic Organization of Dysphagia

Hirano I et al. Clin Gastroenterol Hepatol 2011;9:470-4.

Diagnostic Tests for

Oropharyngeal Dysphagia Speech Pathology

• Cine-video esophagram

– Modified

– Oropharyngeal and esophageal

• Evaluates real-time swallowing and bolus transfer into the

esophagus

ENT

• Direct laryngoscopy

• Stroboscopy

• FEES – fiberoptic endoscopic evaluation of swallowing

Cricopharyngeal Achalasia

Zenker’s Diverticulum

Cervical Spine Disease

Causes of Esophageal Dysphagia

• Mechanical Lesions – Intrinsic

– Benign tumors

– Caustic esophagitis/stricture

– Diverticula

– Malignancy

– Peptic esophagitis/stricture

– Pill esophagitis

– Post surgery (laryngeal, gastric)

– Radiation esophagitis/stricture

– Rings and webs

Gasiorowska and Fass. Gastroenterol Hepatol 2009;5:264-79

Causes of Esophageal Dysphagia (cont.)

• Mechanical lesions – Extrinsic

– Aberrant subclavian artery

– Cervical osteophytes

– Enlarged aorta

– Enlarged left atrium

– Mediastinal mass (lymphadenopathy, lung

cancer, etc.)

– Post surgery (laryngeal, spinal)

Gasiorowska and Fass. Gastroenterol Hepatol 2009;5:264-79

Esophageal Webs and Rings

Strictures / Caustic Ingestion

Gastroesophageal Reflux Disease

Cancer

Causes of Esophageal Dysphagia (cont.)

• Neuromuscular disorders

– Achalasia

– Chagas’ disease

– Diffuse esophageal spasm

– Hypertensive lower esophageal sphincter

– Nonspecific esophageal motility disorder

– Nutcracker esophagus

– Scleroderma

• Functional

– Functional dysphagia

Gasiorowska and Fass. Gastroenterol Hepatol 2009;5:264-79.

Achalasia

Achalasia

Type 1 - Aperistalsis

Treatment – Heller myotomy > pneumatic

dilation

Type 2 - Aperistalsis + intermittent compart-

mentalized pressurization

Treatment – do well with all tx modalities

Type 3 - Well defined lumen obliterating spastic

contractions in distal esophagus

Treatment – worse prognosis after any

therapeutic modality

Type I Type III Type II

Pandolfino JE, et al. Gastroenterology 2008

100

50

0

150 mmHg

30

• Type I achalasia is associated with absent peristalsis and minimal esophageal

body pressurization

• Type II achalasia is associated with pan-esophageal pressurization related to

a compression effect.

• Type III achalasia has evidence of abnormal contractility (spastic)

Clinical Evolution of Achalasia Assessing clinically relevant phenotypes

Diffuse Esophageal Spasm

Diagnostic Tools for

Esophageal Dysphagia

1. Upper endoscopy

- Dysphagia is considered an alarm symptom

2. Barium swallow

- S/P laryngectomy, caustic ingestion and radiation

- after endoscopy – R/O achalasia

3. Bollus challenge esophagram

- Identify subtle obstructive lesions (after

endoscopy)

4. Timed barium emptying

- Achalasia

Esophageal Dysphagia Patients

without Mechanical Obstruction

(Intrinsic or Extrinsic)

• High resolution manometry

• Esophageal impedance – bolus transfer

assessment

• Combined high resolution manometry

and impedance

Normal Esophageal Function

Manometry + Impedance

LES

5cm

10cm

15cm

20cm

5cm

10cm

15cm

20cm

CONTRACTILE ACTIVITY

BOLUS TRANSIT

38 Circumferential

Pressure

Channels

Channel spacing 1

cm

High Resolution Solid State Pressure Probe

Courtesy of Jean Osborne

Case Presentation

• A 28 year-old white man with 2-3-year history

of dysphagia for both solids and liquids

• Food gets stuck in the mid-chest area.

Needs large amount of water to wash it down.

• Sharp chest pain twice a month, lasting up to

15 hours, associated with vomiting

• Placed on PPI once a day with partial

response.

Case Presentation (cont.)

• Patient denies heartburn, coughing, nasal

regurgitation or weight loss

• Diagnosed with Hodgkin’s lymphoma in 2010

– treated with chemotherapy

• Physical exam. – Unremarkable

• Workup:

Upper endoscopy – 4

pH test – 3

Esophageal HRM – 2-3

Case Presentation (cont.)

Case Presentation (Cont.)

• Patient was diagnosed with type II

achalasia

• Considering his therapeutic options

Gastro-esophageal Outflow Obstruction

Absent Peristalsis

Jackhammer Esophagus

This is a 65 year-old African-American man with

history of chronic GERD symptoms, who was

seen for “constant” hiccups, burping and

regurgitation of food (liquids and solids) that

have started after his Nissen fundoplication.

Patient underwent Nissen fundoplication in

2006. Upper endoscopy and barium swallow in

2005 were all normal

Case Presentation

• EGD (2010) – dilated esophagus

• EM (2010) – uninterpretable study

• EGD (2013) – 6cm hernia, extremely dilated

esophagus and epiphrenic diverticulum

On Nexium 40mg twice daily without anorexia

or significant weight loss

Case Presentation (cont.)

Treatment of Dysphagia

Oropharyngeal dysphagia

- Treatment of underlying disorder (Parkinson, thyroid

dysfunction etc.)

- Swallow retraining (S/P C.V.A., etc.)

- Permanently impaired swallowing – feeding

gastrostomy or jejunostomy

- Zenker diverticulum – endoscopic or surgical

intervention

Gasirowska and Fass. Gastroenterol Hepatol 2009;5:269-279.

Treatment of Dysphagia

Esophageal dysphagia (mechanical)

- Mild symptoms – lifestyle modifications

- Anti-reflux medications

- Dilations (Schatzki’s ring, web, stricture, EOE, etc.)

- Topical or systemic steroids, allergy assessment,

elimination diet (EOE)

- Dysphagia lusoria (lifestyle modifications, dilation,

surgery)

- Esophageal stents (benign/malignant lesions)

- Surgery

Gasirowska and Fass. Gastroenterol Hepatol 2009;5:269-279.

Treatment of Esophageal

Motor Disorders • Lifestyle modifications

• Anti-reflux medications

• Warm water with every meal

• Peppermint oil solution

• Diltiazem

• Nitrates

• Empiric dilations

• Pneumatic dilation

• Botolinum toxin injection

• Surgery

• Endoscopic intervention

Gasirowska and Fass. Gastroenterol Hepatol 2009;5:269-279

Functional Dysphagia

(Nonobstructive Dysphagia)

• The presence of dysphagia to solids, liquids

or both in the absence of an obstructive

lesion, GERD or a motility disorder with a

recognized pathologic basis

– Usually a diagnosis of exclusion

– Cause unknown

Dekel & Fass. Curr Gastroenterol Rep 2003;5(4):314-322

Functional Dysphagia

Treatment

• Diet

• Empiric esophageal dilation (2 studies)

– Positive

• 23 patients

• 50 F or a 25F Maloney

• 2 years F/U – 80% and 75% improved, respectively

– Negative

• 83 patients

• Balloon distention (18 mm) vs sham

• 6 months F/U – No difference

• Smooth muscle relaxants (nitrates, calcium channel blocks) (?)

• Pain modulators (TCAs) (?)

• Anxiolytics (?)

Schey & Fass, Current GERD Reports 2007;1:17

Early Gastroenterologists