Dysphagia resident survival guide

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Dysphagia
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Reddy Vadiyala, M.B.B.S.[2]

Synonyms and Keywords: Approach to dysphagia, Dysphagia algorithm, Dysphagia workup, Dysphagia management, Dysphagia diagnostic approach

For the WikiDoc page for this topic, click here

Overview

Dysphagia is defined as "difficulty swallowing." It is a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach. According to the International Classification of Diseases (ICD-10) which is endorsed by the WHO, dysphagia is a symptom rather than a disease. Dysphagia can result from propulsive failure, motility disorders, structural disorders, intrinsic or extrinsic compression of the oropharynx or esophagus. Dysphagia is distinguished from similar symptoms including odynophagia, which is defined as painful swallowing, and globus, which is the sensation of a lump in the throat. The endoscopy for esophageal dysphagia should be performed when the patient presented with symptoms of difficulty swallowing, painful swallowing, and aspiration. This is the standard test performed when the patient has a risk of developing pneumonia and diagnosing swallowing difficulties. Videofluoroscopic swallowing study is performed for oropharyngeal dysphagia. It provides information about delay in initiation of pharyngeal swallowing, nasopharyngeal regurgitation, residue of ingested food within the pharyngeal cavity after swallowing, and aspiration of ingested food. The cornerstone of any dysphagia evaluation is a detailed history and a thorough review of symptoms that can differentiate esophageal from oropharyngeal dysphagia and help predict the specific etiology of dysphagia with an accuracy of approximately 80% confirmed by specific testing. How a patient describes his or her difficulty and its timing, associated symptoms, and other characterizations may specifically denote the anatomic level of swallowing dysfunction.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. There are no known life-threatening causes of dysphagia.

Common Causes

Depending upon the type of dysphagia, the causes can be categorized into two subsections:[1][2][3][4][5][6]

Common Causes of Oropharyngeal Dysphagia

Common causes of oropharyngeal dysphagia
Neuromuscular disorders Mechanical and obstructive causes Medication side effects Others
Medications that reduce salivary flow:

Common Causes of Esophageal Dysphagia

The common causes of esophageal dysphagia can be divided into four categories.[7][8][9][10][11]

Structural (Mechanical) disorders Motor disorders Esophageal tumors Systemic diseases Miscellaneous
Intrinsic compression Extrinsic Compression Primary Secondary
Mucosal rings and webs Strictures: Vascular compression:

Less Common Causes

Less common causes of dysphagia include:

To review a complete list of dysphagia causes, click here

Diagnosis


 
 
 
 
 
 
 
Patient with Dysphagia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Difficulty in initiating a swallow
associated with cough, choking
or nasal regurgitation
 
 
 
 
 
Dysphagia to solids and liquids, or solids,
sensation of food stuck in esophagus
(seconds after initiating swallow)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Oropharyngeal dysphagia
 
 
 
 
 
Esophageal dysphagia
 


Shown below is an algorithm summarizing the diagnosis of Oropharyngeal dysphagia according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.[1][4][2]

 
 
 
 
 
 
 
 
Dysphagia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History and Physical examination
 
 
Identify alternate diagnoses such as xerostomia, globus, esophageal dysphagia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Laboratory findings and CNS imaging
 
 
Identify syndromes with specific treatment such as myasthenia gravis, toxic and metabolic myopathies, CNS tumors
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No systemic disease identified
 
 
 
Neuromuscular disorders without specific treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nasoendoscopy (to evaluate for structural causes of dysphagia)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Videofluoroscopic swallowing +/-manometry (to characterise severity and mechanism of swallow dysfunction)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Structural lesions with specific therapy such as zenker's diverticulum, orophayngeal tumors
 
Severe dysfunction or risk of aspiration pneumonia necessitating the institution of nonoral feeding, tracheostomy
 
 
Dysphagia ammendable to cricophayngeal myotomy
 
Dysphagia ammendable to specific therapy (diet modification, swallow therapy +/- temporary nonoral feeding)
 


Shown below is an algorithm summarizing the diagnosis of Esophageal dysphagia according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.[1][6]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dysphagia to solids and liquids
 
 
 
 
 
 
 
 
 
 
Dysphagia to solids (may progress to liquids)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Motility disorders
 
 
 
 
 
 
 
 
 
 
Mechanical obstruction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intermittent
 
 
 
 
 
Progressive
 
 
 
Acute
 
Intermittent
 
Progressive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chronic heartburn
 
Regurgitation and/or respiratory symptoms
 
 
 
 
 
 
 
 
 
Chronic heartburn
 
Elderly (>50 years), weight loss, anemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary motility disorders
 
Secondary motility disorders
 
Scleroderma
 
Achalasia
 
Foreign body
 
 
 
Esophageal or cardia carcinomas
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Manometry
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endoscopy (+/-esophageal biopsy)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Barium Swallow indicated when:
Endoscopy findings are normal
❑ Endoscopy is contraindicated due to:
❑ History of surgery for esophageal/laryngeal cancer
❑ History of radiation
Caustic injury
❑ Complex stricture
❑ Risk of perforation
Endoscopy access is limited
 
 
 
 

Treatment

Shown below is an algorithm summarizing the treatment of Oropharyngeal dysphagia according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.[1][4][2]

 
 
 
 
 
 
 
 
 
 
Systemic disease with specific therapy
such as myasthenia gravis, myopathies,
parkinson's disease, infections and others
 
Treat the underlying disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CNS tumors and oropharyngeal tumors
 
Surgical resection, chemotherapy or radiotherapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Oropharyngeal dysphagia
 
 
 
 
 
Structural disorders such as cervical webs
and rings, zenker's diverticulum and others
 
Treatment of the disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medication side effects
 
Discontinue medication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe dysfunction and
risk of aspiration pneumonia
 
❑ Non-oral feeding
Tracheostomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neuromuscular disorder without specific therapy such as stroke, dengerative diseases and others
 
 
 
Cricopharynegal dysfunction
 
Cricopharyngeal myotomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rehabilitation
 
Swallowing maneuvers and postural techniques
❑ Dietary modification
❑ Temporary non-oral feeding
 
 
 
 


Shown below is an algorithm summarizing the management of Esophageal dysphagia according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.[1][6]

 
 
Esophageal dysphagia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Age>50 years, weight loss,
anemia and other alarm
signs and symptoms
 
 
Endoscopy +/- other imaging studies
 
 
Surgical resection or
chemotherapyof the detected
esophageal carcinoma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
GERD symptoms
 
 
Proton pump inhibitor trial for 4 weeks
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dysphagia unresolved
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Structural or inflammatory
lesions detected on endoscopy
and/or barium swallow
 
 
Treat the detected lesions
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Esophageal manometry
 
 
Treat the
detected motility disorders
 
 
 
 
 
 
 

Do's

  • Evaluate for drugs causing decreased salivary flow or those causing esophageal mucosal injury.
  • Treat underlying disorders first.

Don'ts

References

  1. 1.0 1.1 1.2 1.3 1.4 Malagelada, Juan-R.; Bazzoli, Franco; Boeckxstaens, Guy; De Looze, Danny; Fried, Michael; Kahrilas, Peter; Lindberg, Greger; Malfertheiner, Peter; Salis, Graciela; Sharma, Prateek; Sifrim, Daniel; Vakil, Nimish; Le Mair, Anton (2015). "World Gastroenterology Organisation Global Guidelines". Journal of Clinical Gastroenterology. 49 (5): 370–378. doi:10.1097/MCG.0000000000000307. ISSN 0192-0790.
  2. 2.0 2.1 2.2 Cook, Ian J.; Kahrilas, Peter J. (1999). "AGA technical review on management of oropharyngeal dysphagia". Gastroenterology. 116 (2): 455–478. doi:10.1016/S0016-5085(99)70144-7. ISSN 0016-5085.
  3. Philpott, Hamish; Garg, Mayur; Tomic, Dunya; Balasubramanian, Smrithya; Sweis, Rami (2017). "Dysphagia: Thinking outside the box". World Journal of Gastroenterology. 23 (38): 6942–6951. doi:10.3748/wjg.v23.i38.6942. ISSN 1007-9327.
  4. 4.0 4.1 4.2 Espitalier, F.; Fanous, A.; Aviv, J.; Bassiouny, S.; Desuter, G.; Nerurkar, N.; Postma, G.; Crevier-Buchman, L. (2018). "International consensus (ICON) on assessment of oropharyngeal dysphagia". European Annals of Otorhinolaryngology, Head and Neck Diseases. 135 (1): S17–S21. doi:10.1016/j.anorl.2017.12.009. ISSN 1879-7296.
  5. Abdel Jalil, Ala' A.; Katzka, David A.; Castell, Donald O. (2015). "Approach to the Patient with Dysphagia". The American Journal of Medicine. 128 (10): 1138.e17–1138.e23. doi:10.1016/j.amjmed.2015.04.026. ISSN 0002-9343.
  6. 6.0 6.1 6.2 Liu, Louis W C; Andrews, Christopher N; Armstrong, David; Diamant, Nicholas; Jaffer, Nasir; Lazarescu, Adriana; Li, Marilyn; Martino, Rosemary; Paterson, William; Leontiadis, Grigorios I; Tse, Frances (2018). "Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia". Journal of the Canadian Association of Gastroenterology. 1 (1): 5–19. doi:10.1093/jcag/gwx008. ISSN 2515-2084.
  7. Xiao Y, Kahrilas PJ, Nicodème F, Lin Z, Roman S, Pandolfino JE (2014). "Lack of correlation between HRM metrics and symptoms during the manometric protocol". Am J Gastroenterol. 109 (4): 521–6. doi:10.1038/ajg.2014.13. PMC 4120962. PMID 24513804.
  8. Enestvedt BK, Williams JL, Sonnenberg A (2011). "Epidemiology and practice patterns of achalasia in a large multi-centre database". Aliment Pharmacol Ther. 33 (11): 1209–14. doi:10.1111/j.1365-2036.2011.04655.x. PMC 3857989. PMID 21480936.
  9. Howard PJ, Maher L, Pryde A, Cameron EW, Heading RC (1992). "Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh". Gut. 33 (8): 1011–5. PMC 1379432. PMID 1398223.
  10. Pandolfino JE, Gawron AJ (2015). "Achalasia: a systematic review". JAMA. 313 (18): 1841–52. doi:10.1001/jama.2015.2996. PMID 25965233.
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  12. Chatterjee S, Hedman BJ, Kirby DF (2017). "An Unusual Cause of Dysphagia". J Clin Rheumatol. doi:10.1097/RHU.0000000000000666. PMID 29280826.
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  16. Benedict, Edward B.; Sweet, Richard H. (1955). "Dysphagia Due to Hypertrophy of the Cricopharyngeus Muscle or Hypopharyngeal Bar". New England Journal of Medicine. 253 (26): 1161–1162. doi:10.1056/NEJM195512292532607. ISSN 0028-4793.