II. Causes: Functional and Inflammatory Esophageal Causes (30-40% of Esophageal Dysphagia)
- Functional esophageal disorders
- Gastroesophageal Reflux
- Acid Hypersensitivity (Reflux Hypersensitivity)
- Functional Dysphagia
- Esophagitis
- Eosinophilic Esophagitis
- Pill Esophagitis
- Infectious Esophagitis (esp. HIV or immunocompromised state)
- See Dysphagia in HIV
- Candida Esophagitis
- Herpes Simplex Virus Esophagitis
- Cytomegalovirus Esophagitis
III. Causes: Neuromuscular and Esophageal Dysmotility Causes
- Cerebrovascular Accident (CVA)
- Electrolyte disturbance
-
Esophageal Dysmotility
- Decreased or inactive esophageal contractility
- Esophageal Achalasia
- Opioid-Induced Esophageal Dysfunction
- Increased esophageal contractility
- Decreased or inactive esophageal contractility
-
Diabetes Mellitus
- See Gastrointestinal Manifestations of Diabetes Mellitus
- More common with increasing duration of Diabetes Mellitus (regardless of type)
IV. Causes: Esophageal Structural Disorders
- Esophageal Ring or Schatzki Ring
- Esophageal Stricture (e.g. erosive esophagitis related)
- Esophageal Foreign Body
- Systemic Sclerosis (Scleroderma)
- Thoracic malignancy
-
Vascular Ring Abnormality
- Dysphagia lusoria (aberrant right subclavian artery)
- Enlarged left atrium
- Enlarged Thoracic Aorta
V. Causes: Medications
- Pill Esophagitis (e.g. Bisphosphonates, Tetracyclines, NSAIDs, Potassium chloride)
- Smooth muscle relaxants (Cause Decreased Lower Esophageal Sphincter or LES Pressure)
VI. History: General
- See Dysphagia
- Does it feel as if food is becoming stuck in your chest?
- Acute Dysphagia
- Progressive Dysphagia?
- Progressive Esophageal Motility Disorder
- Chest mass
- Intermittent?
- Consider Esophageal Dysmotility
- Solid or Liquid Dysphagia?
- Liquid only Dysphagia suggests Oropharynngeal Dysphagia
- Liquid and Solid Dysphagia
- Esophageal Dysmotility (e.g. Achalasia)
- Solid Dysphagia only
- Intrinsic obstruction (e.g. Esophageal Ring, Esophageal Foreign Body, Esophageal Cancer)
- Extrinsic obstruction (e.g. mediastinal chest mass, thyromegaly)
- Medications and Habits
- Pill Esophagitis provocative medications
- Esophageal Dysmotility provocative medications (e.g. Opioids)
- Antacid Medication regular use (e.g. Proton Pump Inhibitors)
- Associated Symptoms
- Dyspepsia
- Painful Swallowing (odynophagia)
- Consider esophagitis (e.g. esophageal Candidiasis, viral esophagitis)
- Reflux of undigested food (esp. overnight) with halitosis
- Consider Zenker Diverticulum
- Environmental Allergies
- Consider Eosinophilic Esophagitis
VII. History: Red Flags
- Weight loss (Consider malignancy)
- Fever
- Odynophagia
- Gastrointestinal Bleeding
- Severe, rapidly progressive symptoms
- Age over 50 years old
VIII. Exam
- See Dysphagia
-
General
- Cachexia or muscle wasting (consider active malignancy)
- Frailty (Sarcopenia)
- Neck
- Cervical Lymphadenopathy
- Thyromegaly or ThyroidGoiter
- Neck Mass
-
Chest
- Wheezing or Stridor
- Asymmetric lung sounds
- Supraclavicular Lymphadenopathy
- Chest mass or deformities
-
Abdomen
- Portal Hypertension findings (e.g. Abdominal Distention, Jaundice, varicosities)
- Abdominal Mass
- Skin Exam
- Scleroderma findings (e.g. sausage digits)
- Skin changes suggestive of chemical dependency (e.g. needle tracks)
IX. Diagnostics
- Upper Endoscopy (EGD)
- First-Line study, indicated for red flag symptoms or symptoms refractory to empiric management
- Evaluates for obstructive lesions, structural deformities, inflammation and infection
- Allows for esophageal dilation in case of Esophageal Stricture
X. Imaging
- Contrast Esophogram
- May be considered in the acute evaluation for structural abnormalities of the esophagus
- Emergency department patient may be given Oral Contrast 60-120 ml (2-4 oz) immediately before upright XRay
- Allows for informal esophagram when radiologist is not available
- CT Chest
- Consider in the evaluation of chest mass suspected in esophageal obstruction
XI. Management
- Expedited assesmment if red flags present (see above)
- Initial empiric management if no red flags
- See Gastroesophageal Reflux for general management
- Proton Pump Inhibitor trial for 4 weeks, and continue for 8-12 weeks if effective or confirmed diagnosis
- Manage specific causes based on diagnostics and differential diagnosis
- Gastroenterology Consultation
- Consider Esophageal Dysmotility in refractory cases (but avoid over diagnosis)
- Other measures for functional esophageal disorders
- See Esophageal Dysmotility for general measures that may be effective in Esophageal Dysphagia
- Avoid Opioids (worsens esophageal motility)
- Prevent Pill Esophagitis
XII. Resources
XIII. References
Images: Related links to external sites (from Bing)
Related Studies
| Definition (NCI) | Difficulty in swallowing due to an abnormality in the esophagus. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D003680 |
| SnomedCT | 40890009 |
| French | Dysphagie oesophagienne |
| English | esophageal dysphagia, oesophageal dysphagia, Esophageal dysphagia, Oesophageal dysphagia, Esophageal dysphagia (disorder), Dysphagia, Esophageal, Esophageal Dysphagia |
| Czech | ezofageální dysfagie |
| Norwegian | Dysfagi som skyldes forstyrrelser i spiserøret |
| Spanish | disfagia esofágica (trastorno), disfagia esofágica |
