Esophageal Dysphagia

Aka: Esophageal Dysphagia, Dysphagia from Esophageal Cause, Causes of Esophageal Dysphagia

1. See Also
   1. Dysphagia
   2. Dysphagia from Oropharyngeal Cause
   3. Swallowing (Deglutition)
   4. Dysphagia Evaluation
   5. Esophageal Dysmotility
2. 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
   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 Virus Esophagitis
         4. Cytomegalovirus Esophagitis
3. 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
         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)
4. Causes: Esophageal Structural Disorders
   1. Esophageal Ring or Schatzki Ring
   2. Esophageal Stricture (e.g. erosive esophagitis related)
   3. Esophageal Foreign Body
   4. Systemic Sclerosis (Scleroderma)
   5. Thoracic malignancy
      1. Gastric Cancer
      2. Mediastinal Mass
      3. Esophageal Cancer
         1. Esophageal Adenocarcinoma
         2. Esophageal Squamous Cell Carcinoma
   6. Vascular Ring Abnormality
      1. Dysphagia lusoria (aberrant right subclavian artery)
      2. Enlarged left atrium
      3. Enlarged Thoracic Aorta
5. Causes: Medications
   1. Pill Esophagitis (e.g. Bisphosphonates, Tetracyclines, NSAIDs, Potassium chloride)
   2. Smooth Muscle relaxants (Cause Decreased Lower Esophageal Sphincter or LES Pressure)
      1. See Causes of Decreased Lower Esophageal Sphincter Pressure
      2. Nitrates
      3. Anticholinergic Medications
      4. Opioids
      5. Benzodiazepines
      6. Calcium Channel Blockers
      7. Tricyclic Antidepressants
      8. Alcohol
      9. Caffeine
6. 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. Chest mass
   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
      1. Dyspepsia
      2. Painful Swallowing (odynophagia)
         1. Consider esophagitis (e.g. esophageal Candidiasis, viral esophagitis)
      3. Reflux of undigested food (esp. overnight) with halitosis
         1. Consider Zenker Diverticulum
      4. Environmental Allergies
         1. Consider Eosinophilic Esophagitis
7. History: Red Flags
   1. Weight loss (Consider malignancy)
   2. Fever
   3. Odynophagia
   4. Gastrointestinal Bleeding
   5. Severe, rapidly progressive symptoms
   6. Age over 50 years old
8. 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 ThyroidGoiter
      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)
9. 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
10. 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
11. 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
12. Resources
    1. Dysphagia (WGO)
       1. https://www.worldgastroenterology.org/UserFiles/file/guidelines/dysphagia-english-2014.pdf
13. References
    1. Wilkinson (2021) Am Fam Physician 103(2): 97-106 [PubMed]