Evaluation of Dysphagia
Causes, Evaluation, and Treatment of Difficulty With Swallowing
Jul 11, 2009
Dysphagia refers to difficulty with swallowing, specifically characterized by impaired movement of solid food, liquids, or both from the pharynx to the stomach. This symptom is more than just an issue of comfort. It poses the risk of complications, especially the possibility of aspiring foreign substances into the trachea and lungs. For these reasons, dysphagia should always warrant medical attention.
Causes
In general, the causes of dysphagia are categorized as oropharyngeal dysphagia or esophageal dysphagia depending on its anatomic location.
- Oropharyngeal Dysphagia: This type of dysphagia is characterized by an inability to carry food from the oral cavity to the beginning of the esophagus. Causes of oropharngeay dysphagia include neurological etiologies such as stroke, multiple sclerosis, amyotrophic lateral sclerosis (Lou Gehrig's disease), and Parkinson's disease as well as muscular conditions affecting coordination of the throat muscles.
- Esophageal Dysphagia: This type of dysphagia involves the blockage of transport of food through the esophagus to the stomach. This may occur secondary to an anatomic obstruction within the esophagus, such as obstruction from esophageal cancer and peptic strictures, or disorders of esophageal motility, including systemic sclerosis, diffuse esophageal spasm, and persistent contraction of the lower esophageal sphincter (achalasia).
Evaluation
Evaluation of dysphagia begins with a patient history to describe the symptom itself. Clues may point to oropharyngeal dysphagia or esophageal dysphagia. For example, drooling, nasal regurgitation, choking, and coughing suggest oropharyngeal dysphagia, whereas the sensation of swallowed food getting stuck on the way down points to esophageal dysphagia. The consistency of food also provides important information because different causes of dysphagia may affect solids, liquids, or both. For instance, esophageal cancer blocks solid foods first but still allows liquids to pass, whereas achalasia obstructs both solids and liquids. Other information includes symptoms related to possible causes for dysphagia, which may be supported by a physical examination in some cases.
An important component of evaluation for dysphagia is the barium swallow. This is a procedure, performed by a speech therapist, in which the patient swallows boluses of barium while x-ray images are taken of the oropharynx, esophagus, and stomach. Depending on the abnormalities seen on imaging, this may be followed up by other tests, such as upper endoscopy to evaluate anatomic abnormalities or esophageal manometry to assess motility of the esophagus.
Treatment
The treatment of dysphagia involves addressing the underlying cause. This may involve procedures such as surgery or esophageal dilation for conditions such as esophageal cancer and strictures, respectively. Other measures include conservative methods, such as correct positions during eating, and rehabilitative exercises that help improve swallow function. These solutions may be helpful for dysphagia due to stroke or other neurological conditions.
References
- Merck Manual - Dysphagia
- Fass, Ronnie. "Approach to the Patient With Dysphagia." In: Rose, Burton D., editor. UpToDate. Waltham, MA: UpToDate, 2009.
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