II. Causes: Functional and Inflammatory Esophageal Causes (30-40% of Esophageal Dysphagia)

  1. Functional esophageal disorders
    1. Gastroesophageal Reflux
    2. Acid Hypersensitivity (Reflux Hypersensitivity)
    3. Functional Dysphagia
      1. Uncommon, diagnosis of exclusion (all other workup as below completed and negative)
      2. Diagnoses requires symptoms once weekly for 3 months and symptom onset within 6 months (Rome 4)
  2. Esophagitis
    1. Eosinophilic Esophagitis
    2. Pill Esophagitis
    3. Infectious Esophagitis (esp. HIV or Immunocompromised state)
      1. See Dysphagia in HIV
      2. Candida Esophagitis
      3. Herpes Simplex VirusEsophagitis
      4. CytomegalovirusEsophagitis

III. Causes: Neuromuscular and Esophageal Dysmotility Causes

  1. Cerebrovascular Accident (CVA)
  2. Electrolyte disturbance
    1. Hypocalcemia
    2. Hypomagnesemia
  3. Esophageal Dysmotility
    1. Decreased or inactive esophageal contractility
      1. Esophageal Achalasia (most common motility disorder)
      2. Opioid-Induced Esophageal Dysfunction
    2. Increased esophageal contractility
      1. Esophageal Spasm
      2. Hypercontractile Esophagus ("Jackhammer Esophagus")
  4. Diabetes Mellitus
    1. See Gastrointestinal Manifestations of Diabetes Mellitus
    2. More common with increasing duration of Diabetes Mellitus (regardless of type)

IV. Causes: Esophageal Structural Disorders

  1. Esophageal Ring or Schatzki Ring
  2. Esophageal Web
  3. Esophageal Stricture (e.g. erosive Esophagitis related)
  4. Esophageal Foreign Body
  5. Systemic Sclerosis (Scleroderma)
    1. May also be combined with other findings of CREST Syndrome
  6. Thoracic malignancy
    1. Gastric Cancer
    2. Mediastinal Mass
    3. Esophageal Cancer
      1. Esophageal Adenocarcinoma
      2. Esophageal Squamous Cell Carcinoma
  7. Vascular Ring Abnormality
    1. Dysphagia lusoria (aberrant right subclavian artery)
    2. Enlarged left atrium
    3. Enlarged Thoracic Aorta

VI. History: General

  1. See Dysphagia
  2. Does it feel as if food is becoming stuck in your chest?
  3. Acute Dysphagia
    1. Pill Esophagitis
    2. Esophageal Foreign Body
    3. Gastroesophageal Reflux Exacerbation
  4. Progressive Dysphagia?
    1. Progressive Esophageal Motility Disorder
    2. Malignancy (Chest mass, Esophageal Cancer or head and neck cancer)
      1. Consider risk factors (e.g. Smoking, heavy Alcohol use)
  5. Intermittent?
    1. Consider Esophageal Dysmotility
  6. Solid or Liquid Dysphagia?
    1. Liquid only Dysphagia suggests Oropharynngeal Dysphagia
    2. Liquid and Solid Dysphagia
      1. Esophageal Dysmotility (e.g. Achalasia)
    3. Solid Dysphagia only
      1. Intrinsic obstruction (e.g. Esophageal Ring, Esophageal Foreign Body, Esophageal Cancer)
      2. Extrinsic obstruction (e.g. mediastinal chest mass, thyromegaly)
  7. Medications and Habits
    1. Pill Esophagitis provocative medications
    2. Esophageal Dysmotility provocative medications (e.g. Opioids)
    3. Antacid Medication regular use (e.g. Proton Pump Inhibitors)
  8. Associated Symptoms or Findings
    1. Dyspepsia
    2. Painful Swallowing (odynophagia)
      1. Consider Esophagitis (e.g. Esophageal Candidiasis, viral Esophagitis)
      2. Consider food impaction in the acute setting
    3. Reflux of undigested food (esp. overnight) with halitosis
      1. Consider Zenker Diverticulum
    4. Environmental Allergies
      1. Consider Eosinophilic Esophagitis
    5. Recurrent Pneumonia or coughing on Swallowing
      1. Consider aspiration
    6. Drooling
      1. Consider esophageal or airway obstruction

VII. History: Red Flags

  1. Weight loss (Consider malignancy)
  2. Fever
  3. Odynophagia (painful Swallowing)
  4. Gastrointestinal Bleeding
  5. Severe, rapidly progressive symptoms
  6. Age over 50 years old

VIII. Exam

  1. See Dysphagia
  2. General
    1. Cachexia or Muscle wasting (consider active malignancy)
    2. Frailty (Sarcopenia)
  3. Neck
    1. Cervical Lymphadenopathy
    2. Thyromegaly or Thyroid Goiter
    3. Neck Mass
  4. Chest
    1. Wheezing or Stridor
    2. Asymmetric lung sounds
    3. Supraclavicular Lymphadenopathy
    4. Chest mass or deformities
  5. Abdomen
    1. Portal Hypertension findings (e.g. Abdominal Distention, Jaundice, varicosities)
    2. Abdominal Mass
  6. Skin Exam
    1. Scleroderma findings (e.g. Sausage Digits)
    2. Skin changes suggestive of chemical dependency (e.g. needle tracks)

IX. Differential Diagnosis

  1. See Oropharyngeal Dysphagia (includes CVA)

X. Diagnostics

  1. Upper Endoscopy (EGD)
    1. First-Line study, indicated for red flag symptoms or symptoms refractory to empiric management
    2. Evaluates for obstructive lesions, structural deformities, inflammation and infection
    3. Allows for esophageal dilation in case of Esophageal Stricture

XI. Imaging

  1. Contrast Esophogram
    1. May be considered in the acute evaluation for structural abnormalities of the Esophagus
    2. Emergency department patient may be given Oral Contrast 60-120 ml (2-4 oz) immediately before upright XRay
      1. Allows for informal esophagram when radiologist is not available
  2. CT Chest
    1. Consider in the evaluation of chest mass suspected in esophageal obstruction

XII. Management

  1. Expedited assesmment if red flags present (see above)
  2. Initial empiric management if no red flags
    1. See Gastroesophageal Reflux for general management
    2. Proton Pump Inhibitor trial for 4 weeks, and continue for 8-12 weeks if effective or confirmed diagnosis
  3. Manage specific causes based on diagnostics and differential diagnosis
    1. Gastroenterology Consultation
    2. Consider Esophageal Dysmotility in refractory cases (but avoid over diagnosis)
  4. Other measures for functional esophageal disorders
    1. See Esophageal Dysmotility for general measures that may be effective in Esophageal Dysphagia
    2. Avoid Opioids (worsens esophageal motility)
    3. Prevent Pill Esophagitis

XIV. References

  1. Hagen and Pickle (2023) Crit Dec Emerg Med 37(6): 24-9
  2. Wilkinson (2021) Am Fam Physician 103(2): 97-106 [PubMed]

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