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
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