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Dysphagia
is difficulty swallowing. The usual complaint is that food “gets
stuck” on the way down.
The condition results from impeded transport of liquids, solids, or both from the pharynx to the stomach. Dysphagia is classified as oropharyngeal or esophageal, depending on where it occurs. Dysphagia should not be confused with globus sensation (see Approach to the Patient with Upper GI Complaints: Globus Sensation), a feeling of having a lump in the throat, which is unrelated to swallowing and occurs without impaired transport.
Oropharyngeal
Dysphagia
Oropharyngeal
dysphagia is difficulty emptying material from the oropharynx into
the esophagus; it results from abnormal function proximal to the
esophagus.
Most often, this occurs in patients with neurologic conditions or muscular disorders that affect skeletal muscles. Neurologic conditions include Parkinson's disease, stroke, multiple sclerosis, amyotrophic lateral sclerosis, bulbar poliomyelitis, pseudobulbar palsy, and other CNS lesions. Muscular disorders include dermatomyositis, myasthenia gravis, and muscular dystrophy.
Symptoms include difficulty initiating swallowing, nasal regurgitation, and tracheal aspiration followed by coughing. Diagnosis is by direct observation and videotaped barium swallow. Treatment is directed at the underlying condition.
Esophageal
Dysphagia
Esophageal
dysphagia is difficulty passing food down the esophagus. It can
result from either a mechanical obstruction or a motility disorder.
Causes of mechanical obstruction include intrinsic disorders such as peptic strictures, esophageal cancer, and lower esophageal rings. Mechanical obstruction can also result from extrinsic disorders that compress the esophagus, including an enlarged left atrium, aortic aneurysm, vascular abnormalities such as an aberrant subclavian artery (dysphagia lusoria), substernal thyroid, cervical bony exostosis, and a thoracic tumor—most commonly lung cancer. Rarely, the esophagus is involved by lymphoma, leiomyosarcoma, or metastatic cancer. Caustic ingestion often results in significant stricture.
Motility disorders cause dysphagia by disrupting function of esophageal smooth muscle (ie, impairing esophageal peristalsis and lower esophageal sphincter function). Motility disorders include achalasia and diffuse esophageal spasm. Systemic sclerosis may cause a motility disorder.
Symptoms and Signs
Motility disorders produce dysphagia for both solids and liquids; mechanical obstruction produces dysphagia for solids alone. Meat and bread cause the most difficulty; however, some patients cannot tolerate any solids. Patients who complain of dysphagia in the lower esophagus are usually correct about the condition's location, whereas patients who complain of dysphagia in the upper esophagus are often incorrect.
Dysphagia can be intermittent (eg, from lower esophageal ring or diffuse esophageal spasm), progress rapidly over weeks to months (eg, from esophageal cancer), or progress over years (eg, from peptic stricture). Patients whose dysphagia is caused by peptic stricture usually have a prominent history of gastroesophageal reflux disease.
Diagnosis
and Treatment
Dysphagia for both liquids and solids helps distinguish motor from obstructive causes. A barium swallow (with a solid bolus, usually a marshmallow or tablet) should be performed. If this shows obstruction, endoscopy (and possibly biopsy) should be performed to rule out malignancy. If the barium swallow is negative or suggestive of a motility disorder, esophageal motility studies should be performed. Treatment is directed at the specific cause.
Cricopharyngeal Incoordination
In cricopharyngeal incoordination, the cricopharyngeal muscle (the upper esophageal sphincter) is uncoordinated. It can cause a Zenker's diverticulum; repeated aspiration of material from the diverticulum can lead to chronic lung disease. The condition can be treated by surgical section of the cricopharyngeal muscle.
Last full review/revision November 2005
Content last modified November 2005
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