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Esophageal Dysphagia
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Esophageal Dysphagia
, Dysphagia from Esophageal Cause, Causes of Esophageal Dysphagia
See Also
Dysphagia
Dysphagia from Oropharyngeal Cause
Swallowing
(
Deglutition
)
Dysphagia Evaluation
Esophageal Dysmotility
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
Causes
Neuromuscular and
Esophageal Dysmotility
Causes
Cerebrovascular Accident
(CVA)
Electrolyte
disturbance
Hypocalcemia
Hypomagnesemia
Esophageal Dysmotility
Decreased or inactive esophageal contractility
Esophageal Achalasia
Opioid
-Induced Esophageal Dysfunction
Increased esophageal contractility
Esophageal Spasm
Hypercontractile Esophagus
("
Jackhammer Esophagus
")
Diabetes Mellitus
See
Gastrointestinal Manifestations of Diabetes Mellitus
More common with increasing duration of
Diabetes Mellitus
(regardless of type)
Causes
Esophageal Structural Disorders
Esophageal Ring
or
Schatzki Ring
Esophageal Stricture
(e.g. erosive esophagitis related)
Esophageal Foreign Body
Systemic Sclerosis
(
Scleroderma
)
Thoracic malignancy
Gastric Cancer
Mediastinal Mass
Esophageal Cancer
Esophageal Adenocarcinoma
Esophageal
Squamous Cell Carcinoma
Vascular Ring
Abnormality
Dysphagia
lusoria (aberrant right subclavian artery)
Enlarged left atrium
Enlarged Thoracic Aorta
Causes
Medications
Pill Esophagitis
(e.g.
Bisphosphonates
,
Tetracyclines
,
NSAID
s,
Potassium
chloride)
Smooth Muscle
relaxants (Cause Decreased Lower Esophageal Sphincter or LES Pressure)
See
Causes of Decreased Lower Esophageal Sphincter Pressure
Nitrates
Anticholinergic Medication
s
Opioid
s
Benzodiazepine
s
Calcium Channel Blocker
s
Tricyclic Antidepressant
s
Alcohol
Caffeine
History
Gene
ral
See
Dysphagia
Does it feel as if food is becoming stuck in your chest?
Acute
Dysphagia
Pill Esophagitis
Esophageal Foreign Body
Gastroesophageal Reflux
Exacerbation
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.
Opioid
s)
Antacid
Medication regular use (e.g.
Proton Pump Inhibitor
s)
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
History
Red Flags
Weight loss (Consider malignancy)
Fever
Odynophagia
Gastrointestinal Bleeding
Severe, rapidly progressive symptoms
Age over 50 years old
Exam
See
Dysphagia
Gene
ral
Cachexia
or
Muscle
wasting (consider active malignancy)
Frailty
(
Sarcopenia
)
Neck
Cervical Lymphadenopathy
Thyromegaly or
Thyroid Goiter
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)
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
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
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
Opioid
s (worsens esophageal motility)
Prevent
Pill Esophagitis
Resources
Dysphagia
(WGO)
https://www.worldgastroenterology.org/UserFiles/file/guidelines/dysphagia-english-2014.pdf
References
Wilkinson (2021) Am Fam Physician 103(2): 97-106 [PubMed]
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