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| {{Infobox_Disease | | | __NOTOC__ |
| Name = {{PAGENAME}} |
| | {| class="infobox" style="float:right;" |
| ICD10 = {{ICD10|R|13||r|10}} |
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| ICD9 = {{ICD9|787.2}} |
| | | [[File:Siren.gif|30px|link=Dysphagia resident survival guide]]|| <br> || <br> |
| ICDO = |
| | | [[Dysphagia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| Image = |
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| Caption = |
| | {{Dysphagia}} |
| OMIM = |
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| MedlinePlus = 003115 |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| DiseasesDB = 17942 |
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| }}
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| {{SI}}
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| {{CMG}} | |
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| ==Overview==
| | '''For patient information on this page, click [[Dysphagia (patient information)|here]]''' |
| '''Dysphagia''' ({{IPA|/dɪsˈfe(ɪ)ʒjə/}}) is a medical term defined as "difficulty swallowing." It derives from the Greek root ''dys'' meaning difficulty or disordered, and ''phagia'' meaning "to eat". It is a sensation that suggests difficulty in the passage of solids or liquids from the [[mouth]] to the [[stomach]].<ref> Sleisinger and Fordtran's Gastrointestinal and Liver Disease, 7th edition, Chapter 6, p. 63 </ref> Dysphagia is distinguished from similar symptoms including [[odynophagia]], which is defined as painful swallowing, and [[Globus Pharyngis|globus]], which is the sensation of a lump in the throat. A psychogenic dysphagia is known as [[phagophobia]]. | |
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| It is also worthwhile to refer to the [[swallowing|physiology of swallowing]] in understanding dysphagia.
| | {{CMG}}; {{AE}} {{FT}}, {{HQ}} |
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| ==Epidemiology==
| | {{SK}} [[Dysphagia|Difficulty swallowing]] |
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| Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions.<ref name="Logemann">{{cite book |author=Logemann, Jeri A. |title=Evaluation and treatment of swallowing disorders |publisher=Pro-Ed |location=Austin, Tex |year=1998 |pages= |isbn=0-89079-728-5 |oclc= |doi=}}</ref> Swallowing problems are a common complaint among older individuals, and the [[incidence]] of dysphagia is higher in the [[elderly]],<ref> Shamburek RD; Farrar JT. Disorders of the digestive system in the elderly. N Engl J Med 1990 Feb 15;322(7):438-43. </ref> in patients who have had [[stroke]]s,<ref> Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005 Dec;36(12):2756-63. Epub 2005 Nov 3. </ref> and in patients who are admitted to acute care hospitals or [[chronic care]] facilities. Other causes of dysphagia include [[head and neck cancer]] and progressive neurologic diseases like [[Parkinson's disease]], [[Multiple sclerosis]], or [[Amyotrophic lateral sclerosis]]. Dysphagia is a symptom of many different causes, which can usually be elicited by a careful history by the treating [[physician]].<ref> Schatzki R. Panel discussion on diseases of the esophagus. Am J Gastro. 31:117 (1959). </ref> It should be noted that some patients with dysphagia are not aware of the problem.<ref name="Logemann"> </ref>
| | ==[[Dysphagia overview|Overview]]== |
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| Dysphagia is classified into two major types: '''oropharyngeal''' dysphagia (or '''transfer''' dysphagia) and '''esophageal''' dysphagia. In some patients, no organic cause for dysphagia can be found, and these patients are defined as having '''functional''' dysphagia. | | ==[[Dysphagia historical perspective|Historical Perspective]]== |
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| ==Causes== | | ==[[Dysphagia classification|Classification]]== |
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| In alphabetical order. <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
| | ==[[Dysphagia pathophysiology|Pathophysiology]]== |
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| * [[Abscess]]
| | ==[[Dysphagia causes|Causes]]== |
| * [[Achalasia]]
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| * [[Aerophagia]]
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| * [[Agranulocytosis]]
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| * [[Alcoholism]]
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| * [[Allergic]] swelling
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| * [[Amyloidosis]]
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| * [[Amyotrophic Lateral Sclerosis]] ([[ALS]])
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| * Angina tonsillaris
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| * [[Anxiety]] disorders
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| * [[Aortic aneurysm]]
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| * Aspiration of foreign body
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| * [[Barret's Syndrome]]
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| * [[Behcet's Syndrome]]
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| * [[Botulism]]
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| * [[Brainstem]] [[stroke]]
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| * [[Bronchial carcinoma]]
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| * [[Bulbar palsy]]
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| * [[Candidiasis]]
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| * Cascade stomach
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| * Central [[hypoglossal nerve]] paralysis
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| * Central vagal nucleus lesion
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| * [[Cerebrovascular accident]] ([[CVA]])
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| * [[Chagas Disease]]
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| * Chemical [[burns]]
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| * [[CREST syndrome]]: ([[calcinosis]], [[raynaud's phenomenon]], [[esophageal]] dysmotility, [[sclerodactyly]], [[telangiectasias]])
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| * [[Cytomegalovirus]] ([[CMV]])
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| * [[Dermatomyositis]]
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| * [[Diabetic neuropathy]]
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| * [[Diphtheria]]
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| * [[Diverticulum]]
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| * [[Left Atrial Enlargement|Enlarged left atrium]]
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| * [[Esophageal cancer]]
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| * Esophageal [[Crohn's disease]]
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| * [[Esophageal diverticulum]]
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| * Esophageal [[moniliasis]]
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| * Esophageal [[sarcoidosis]]
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| * [[Esophageal spasm]]
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| * Esophageal [[trauma]]
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| * [[Esophagotracheal fistula]]
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| * Extreme spinal curvature
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| * [[Fibrosis]]
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| * Food bolus
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| * [[Gastric cancer]]
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| * [[Gastritis]]
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| * [[Gastroparesis]]
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| * [[Global hystericus]]
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| * [[Globus syndrome]]
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| * [[Goiter]]
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| * [[Graft-versus-host disease]]
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| * [[Guillain-Barre Syndrome]]
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| * [[Herpangina]]
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| * [[Herpes simplex virus]] ([[HSV]])
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| * [[Hiatal hernia]]
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| * [[Huntington's chorea]]
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| * [[Hyperthyroidism]]
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| * [[Hypokalemia]]
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| * [[Hypothyroidism]]
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| * Idiopathic [[human immunodeficiency virus]][[HIV]] [[ulcer]]s
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| * Impaired sensitivity in the [[larynx]]
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| * Intramural pseudodiverticulosis
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| * [[Laryngeal cancer]]
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| * [[Lateral funiculus]] [[angina]]
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| * [[Leiomyoma]]
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| * [[Ludwig's angina]]
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| * Lymph granulomatosis
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| * [[Lymphadenopathy]]
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| * Medication-induced [[esophagitis]]
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| * [[Mononucleosis]]
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| * [[Multiple Sclerosis]]
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| * [[Mumps]]
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| * [[Myasthenia Gravis]]
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| * [[Neoplastic]] (external compression)
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| * [[Nutcracker esophagus]]
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| * [[Oral candidiasis]]
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| * [[Osteophytes]]
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| * [[Palatoplegia]] after damage to the [[vagal nerve]] or the accessory nerve
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| * [[Paraneoplastic syndrome]]
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| * [[Parkinson's Disease]]
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| * [[Pericarditis]]
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| * [[Peripheral neuropathy]]
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| * Peripheral tongue paralysis with lesions of the [[hypoglossal nerve]]
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| * [[Pharyngitis]]
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| * [[Pleuritis]]
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| * [[Plummer-Vinson Syndrome]]
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| * [[Poliomyelitis]]
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| * [[Polyradiculitis]]
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| * [[Pseudoachalasia]]
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| * [[Pseudobulbar paralysis]]
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| * [[Pyloric stenosis]]
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| * [[Rabies]]
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| * [[Radiation esophagitis]]
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| * [[Reflux esophagitis]]
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| * [[Rheumatoid Arthritis]]
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| * [[Scarlet Fever]]
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| * [[Schatzki ring]]
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| * [[Scleroderma]]
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| * [[Stevens-Johnson Syndrome]]
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| * [[Stomatitis]]
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| * [[Syringobulbia]]
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| * [[Systemic Lupus Erythematosus]]
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| * [[Tetanus]]
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| * Tonsillar [[abscess]]
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| * [[Typhoid fever]] angina
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| * Vascular abnormality
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| * [[Vincent's angina]]
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| * [[Zenker's Diverticulum]]
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| ==Oropharyngeal dysphagia==
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| Arises from abnormalities of the upper [[esophagus]], [[pharynx]], and [[oral cavity]].
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| ===Signs and symptoms===
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| Some signs and symptoms of swallowing difficulties or dysphagia include the inability to recognize food and taste it, difficulty placing food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent [[pneumonia]], unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and patient complaint of swallowing difficulty.<ref name="Logemann"> </ref> When asked where the food is getting stuck patients will often point to the [[cervical]] (neck) region as the site of the obstruction. However, this may be misleading due to patients' inaccurate sensation of the site of obstruction (with obstructions / dysmotilities lower in the esophagus being common).
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| ===Symptoms of dysphagia in adults may include:=== | | ==[[Dysphagia differential diagnosis|Differentiating Dysphagia from other Conditions]]== |
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| *Hesitation or inability to swallow
| | ==[[Dysphagia epidemiology and demographics|Epidemiology and Demographics]]== |
| *Difficult or painful swallowing
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| *Constant feeling of a lump in the throat
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| *Food sticking in the throat
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| *Food coming up (regurgitation) through the throat or nose
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| *[[Chest pain]] or discomfort when swallowing
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| *Difficulty swallowing solid foods
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| *Frequent, repetitive swallowing
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| *Excessive throat clearing
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| *"Gurgly" sounding voice after eating
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| *Hoarse voice or recurrent sore throat
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| *Coughing during or after swallowing
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| *Necessity to "wash down" solid foods
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| *Recurrent episodes of pneumonia
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| *Frequent heartburn
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| *Food or stomach acid backing up into your throat (acid reflux)
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| *Unexpected [[weight loss]]
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| ===In infants and children, signs and symptoms may include:=== | | ==[[Dysphagia risk factors|Risk Factors]]== |
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| *Low interest in feeding or meals
| | ==[[Dysphagia screening|Screening]]== |
| *Tension in the body while feeding
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| *Refusal to eat foods that have certain textures
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| *Lengthy feeding or eating times (30 minutes or longer)
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| *Food or liquid leaking from the mouth
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| *Coughing or gagging when eating or nursing
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| *Spitting up or vomiting during feeding or meals
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| *Strained breathing while eating and drinking
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| *Poor weight gain or growth
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| ===Complications=== | | ==[[Dysphagia natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| If left untreated, dysphagia can potentially cause [[aspiration pneumonia]], [[malnutrition]], or [[dehydration]], all of which can be symptoms of dysphagia as well.<ref name="Logemann"> </ref>
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| ===Etiology and differential diagnosis=== | | ==Diagnosis== |
| * A [[stroke]] can trigger a rapid onset of dysphagia with a high occurrence of aspiration. The function of normal [[swallowing]] may or may not return completely following an acute phase lasting approximately 6 weeks. <ref name="Murray">Murray, J. (1999). ''Manual of Dysphagia Assessment in Adults''. San Diego: Singular Publishing. </ref>
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| * [[Parkinson's disease]] can cause "multiple prepharyngeal, pharyngeal, and esophageal abnormalities". The severity of the disease most often correlates with the severity of the swallowing disorder.<ref name="Murray"> </ref>
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| * Neurologic disorders such as [[stroke]], [[Parkinson's disease]], [[amyotrophic lateral sclerosis]], [[Bell's palsy]], or [[myasthenia gravis]] can cause weakness of facial and lip muscles that are involved in coordinated mastication as well as weakness of other important [[Mastication#Muscles of mastication|muscles of mastication]] and swallowing.
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| * [[Oculopharyngeal muscular dystrophy]] is a genetic disease with palpebral [[ptosis (eyelid)|ptosis]], oropharyngeal dysphagia, and proximal limb weakness.
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| * Decrease in salivary flow, which can lead to dry mouth or [[xerostomia]], can be due to [[Sjogren's syndrome]], [[anticholinergics]], [[antihistamines]], or certain [[antihypertensives]] and can lead to incomplete processing of food bolus.
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| * [[Xerostomia]] can reduce the volume and increase the [[viscosity]] of oral secretions making [[Bolus (digestion)|bolus]] formation difficult as well as reducing the ability to initate and swallow the bolus<ref name="Murray"> </ref>
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| * Dental problems can lead to inadequate chewing.
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| * Abnormality in oral mucosa such as from [[mucositis]], aphthous [[ulcer]]s, or [[Herpes simplex virus|herpetic lesions]] can interfere with [[Bolus (digestion)|bolus]] processing.
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| * Mechanical obstruction in the oropharynx may be due to malignancies, cervical rings or webs, or cervical [[osteophytes]].
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| * Increased upper esophageal sphincter tone can be due to [[Parkinson's disease]] which leads to incomplete opening of the UES. This may lead to formation of a [[Zenker's diverticulum]].
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| * [[Pharyngeal pouch]]es typically cause difficulty in swallowing after the first mouthful of food, with regurgitation of the pouch contents. These pouches are also marked by malodorous breath due to decomposing foods residing in the pouches. (See [[Zenker's diverticulum]])
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| * Dysphagia is often a side effect of surgical procedures like anterior [[cervical spine]] surgery, [[carotid endarterectomy]], head and neck resection, oral surgeries like removal of the tongue, and parietal laryngectomies <ref name="Murray"> </ref>
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| * [[Radiotherapy]], used to treat head and neck cancer, can cause tissue [[fibrosis]] in the irradiated areas. Fibrosis of [[tongue]] and [[larynx]] lead to reduced tongue base retraction and laryngeal elevation during swallowing<ref name="Murray"> </ref>
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| * Infection may cause [[pharyngitis]] which can prevent swallowing due to [[Pain and nociception|pain]].
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| * Medications can cause [[central nervous system]] effects that can result in an oropharyngeal dysphagia. Examples: [[sedatives]], hypnotic agents, [[anticonvulsants]], [[antihistamines]], [[neuroleptics]], [[barbiturates]], and antiseizure medication. Medications can also cause [[peripheral nervous system]] effects resulting in an oropharyngeal dysphagia. Examples: [[corticosteroids]], [[L-tryptophan]], and [[anticholinergic]]s<ref name="Murray"> </ref>
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| ===Assessment of adults===
| | [[Dysphagia history and symptoms|History and Symptoms]] | [[ Dysphagia physical examination|Physical Examination]] | [[Dysphagia laboratory findings|Laboratory Findings]] | [[ Dysphagia chest x ray|Chest X Ray]] | [[ Dysphagia x ray|X Ray]] | [[ Dysphagia barium swallow|Barium Swallow]] | [[ Dysphagia endoscopy|Endoscopy]] | [[Dysphagia CT|CT]] | [[Dysphagia MRI|MRI]] | [[ Dysphagia ultrasound|Ultrasound]] | [[ Dysphagia other imaging findings|Other Imaging Findings]] | [[Dysphagia other diagnostic studies|Other Diagnostic Studies]] |
| A Speech Language Pathologist is most often the first person called upon to evaluate a patient with suspected dysphagia. During this informal examination, medical history is obtained, the [[mini-mental state examination]] is administered, and oral and facial sensorimotor function, speech, and swallowing are evaluated non-instrumentally.
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| A patient needing further investigation will most likely receive a Modified Barium Swallow (MBS). Different consistencies of liquid and food mixed with [[barium]] sulfate are fed to the patient by spoon, cup or syringe, and x-rayed using videofluoroscopy. A patient's swallowing then can be evaluated and described. Some clinicians might choose to describe the swallow in detail, making mention of any delays or deviations from the norm. Others might choose to use a rating scale such as the Penetration Aspiration Scale. The scale was developed to describe the disordered physiology of a person's swallow using the numbers 1-8.<ref>Rosenbek, J. C., Robbins J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration aspiration scale. "Dysphagia, 11," 93-98.</ref> Other scales also exist for this purpose.
| | ==Treatment== |
| | [[Dysphagia medical therapy|Medical Therapy]] | [[Dysphagia surgery |Surgery]] | [[ Dysphagia primary prevention|Primary Prevention]] | [[ Dysphagia secondary prevention|Secondary Prevention]] | [[ Dysphagia cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[ Dysphagia future or investigational therapies|Future or Investigational Therapies]] |
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| A patient can also be assessed using [[videoendoscopy]], also known as [[flexible fiberoptic endoscopic examination of swallowing]] ([[FEES]]). The instrument, is placed into the nose until the clinician can view the [[pharynx]] and then he or she examines the pharynx and [[larynx]] before and after swallowing. During the actual swallow, the camera is blocked from viewing the anatomical structures. A rigid scope, placed into the oral cavity to view the structures of the pharynx and larynx, can also be used, however; the patient cannot swallow.<ref name="Logemann"> </ref>
| | ==Case Studies== |
| | [[Dysphagia case study one|Case #1]] |
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| Other less frequently used assessments of swallowing are imaging studies, [[ultrasound]] and [[scintigraphy]] and nonimaging studies, [[electromyography]] (EMG), electroglottography (EGG) (records vocal fold movement), cervical [[auscultation]], and pharyngeal [[manometry]].<ref name="Logemann"> </ref>
| | ==Related Chapters== |
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| ===Treatment=== | |
| After assessment, a Speech Language Pathologist will determine the safety of the patient's swallow and recommend treatment accordingly. The Speech Language Pathologist will also advise staff/caregivers and give information about what signs to look for to know if the client is aspirating (e.g. coughing, choking, voice quality becoming 'wet' or 'gurgly', chest colds, recurrent pneumonia) and feeding instructions if required, including posture while eating, consistency of food, and size of mouthfuls.
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| ====Postural techniques.<ref name="Logemann"> </ref>====
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| * Head back (extension) – used when movement of the bolus from the front of the mouth to the back is inefficient; this allows gravity to help move the food.
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| * Chin down (flexion) – used when there is a delay in initiating the swallow; this allows the valleculae to widen, the airway to narrow, and the epiglottis to be pushed towards the back of the throat to better protect the airway from food.
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| * Chin down (flexion) – used when the back of the tongue is too weak to push the food towards the pharynx; this causes the back of the tongue to be closer to the pharyngeal wall.
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| * Head rotation (turning head to look over shoulder) to damaged or weaker side with chin down – used when the airway is not protected adequately causing food to be [[Pulmonary aspiration|aspirated]]; this causes the epiglottis to be put in a more protective position, it narrows the entrance of the airway, and it increases [[vocal fold]] closure.
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| * Lying down on one side – used when there reduced contraction of the pharynx causing excess residue in the pharynx; this eliminates the pull of gravity that may cause the residue to be aspirated when the patient resumes breathing.
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| * Head rotation to damaged or weaker side – used when there is [[paralysis]] or [[paresis]] on one side of the pharyngeal wall; this causes the bolus to go down the stronger side.
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| * Head tilt (ear to shoulder) to stronger side – used when there is weakness on one side of the oral cavity and pharyngeal wall; this causes the bolus to go down the stronger side.
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| ====Swallowing Maneuvers.<ref name="Logemann"> </ref>====
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| * Supraglottic swallow - The patient is asked to take a deep breath and hold their breath. While still holding their breath they are to swallow and then immediately cough after swallowing. This technique can be used when there is reduced or late vocal fold closure or there is a delayed pharyngeal swallow.
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| * Super-supraglottic swallow - The patient is asked to take a breath, hold their breath tightly while bearing down, swallow while still holding the breath hold, and then coughing immediately after the swallow. This technique can be used when there is reduced closure of the airway.
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| * Effortful swallow - The patient is instructed to squeeze their muscles tightly while swallowing. This may be used when there is reduced posterior movement of the tongue base.
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| * Mendelsohn maneuver - The patient is taught how to hold their [[adam's apple]] up during a swallow. This technique may be used when there is reduced laryngeal movement or a discoordinated swallow.
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| ====Diet modification====
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| Diet modification may be warranted. Some patients require a [[soft diet]] that is easily chewed, and some require liquids of a thickened or thinned consistency.
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| -Environmental modification can be suggested to assist and reduce risk factors for aspiration. For example: having the patient use a straw while drinking liquids, putting a pillow behind the patient's head during feeding, removing distractors like too many people in the room or turning off the TV during feeding, etc.
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| ====Oral sensory awareness techniques====
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| Oral sensory awareness techniques can be used with patients who have a swallow apraxia, tactile [[agnosia]] for food, delayed onset of the oral swallow, reduced oral sensation, or delayed onset of the pharyngeal swallow.<ref name="Logemann"> </ref>
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| * pressure of a spoon against tongue
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| * using a sour bolus
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| * using a cold bolus
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| * using a bolus that requires chewing
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| * using a bolus larger than 3mL
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| * thermal-tactile stimulation (controversial)
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| ====Vitalstim Therapy====
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| Vitalstim Therapy ([http://www.vitalstim.com/aboutvs.asp?section=patient&topic=whatisvs]) or electrical stimulation (E-stim) is targeted for oropharyngeal dysphagia and uses electrical stimulation to retrain the muscles used in swallowing. This type of therapy being used in a clinical setting is also very controversial because it lacks evidence of effectiveness. Please see external links for more information.
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| ====Prosthetics====
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| * [[Palatal lift]] or [[obturator]]
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| * Maxillary denture
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| ====Surgical treatment====
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| Surgical treatments are usually only recommended as a last resort.
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| * [[Tracheotomy]]
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| * [[Tracheostomy]]
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| * Vocal fold augmentation/injection
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| * Thryoplasty medialization
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| * [[Arytenoid]] adduction
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| * Partial or total [[laryngectomy]]
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| * Laryngotracheal separation
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| * Supralaryngetomy
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| * [[Palatoplasty]]
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| * Cricopharyngeal Myotomy
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| * Zenker's Diverticulectomy
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| * [[Percutaneous endoscopic gastrostomy]]
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| ==Esophageal dysphagia==
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| Arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach. Usually due to mechanical causes or motility problems.
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| ===Symptoms, signs, and evaluation===
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| Patients usually experience food getting stuck ''several seconds'' after swallowing, and will point to the suprasternal notch or behind the sternum as the site of obstruction. If there is dysphagia to both solids and liquids, then it is most likely a motility problem. If there is dysphagia initially to solids but progresses to also involve liquids, then it is most likely a mechanical obstruction. Once a distinction has been made between a motility problem and a mechanical obstruction, it is important to note whether the dysphagia is intermittent or progressive. An intermittent motility dysphagia likely can be [[diffuse esophageal spasm]] (DES) or nonspecific esophageal motility disorder (NEMD). Progressive motility dysphagia disorders include [[scleroderma]] or [[achalasia]] with chronic heartburn, regurgitation, respiratory problems, or weight loss. Intermittent mechanical dysphagia is likely to be an esophageal ring. Progressive mechanical dysphagia is most likely due to peptic stricture or [[esophageal cancer]].
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| ===Tree diagram of esophageal dysphagia===
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| Schematically the above can be presented as a tree diagram:
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| {{familytree/start}}
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| {{familytree | | | | | | | | | | | | | | A01 | | | | | | | | | | |A01=<small>Esophageal<br>dysphagia</small>}}
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| {{familytree | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | |}}
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| {{familytree | | | | | | | | B01 | | | | | | | | | | B02 | | | | |B01=<small>Solids & liquids<br>(Neuromuscular)<small>|B02=<small>Solids only<br>(Mechanical obstruction)</small>}}
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| {{familytree | | | | |,|-|-|-|^|-|-|-|.| | | |,|-|-|-|^|-|-|-|.| |}}
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| {{familytree | | | | C01 | | | | | | C02 | | C03 | | | | | | C04 | |C01=<small>Progressive</small> |C02=<small>Intermittent</small> |C03=<small>Intermittent</small> |C04=<small>Progressive</small>}}
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| {{familytree | |,|-|-|^|-|-|.| | | | |!| | | |!| | | | |,|-|-|^|-|-|.| |}}
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| {{familytree | D01 | | | | D02 | | | D03 | | D04 | | | D05 | | | | D06 | D01=<small>[[Scleroderma]]</small>|D02=<small>[[Achalasia]]</small>|D03=<small>Diffuse esophageal<br>spasm</small>|D04=<small>Lower esophageal ring</small>|D05=<small>[[esophageal cancer|Cancer]]</small>|D06=<small>Peptic stricture</small>}}
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| {{familytree/end}}
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| ===[[Etiology]] and [[differential diagnosis]] (causes)===
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| [[Image:Peptic stricture.png|left|thumb|200px|[[Gastroscopy|Endoscopic]] image of peptic stricture, or narrowing of the [[esophagus]] near the junction with the [[stomach]]. This is a complication of chronic gastroesophageal reflux disease, and can be a cause of dysphagia.]]
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| '''''Peptic stricture''''', or narrowing of the esophagus, is usually a complication of acid reflux, most commonly due to [[gastroesophageal reflux]] ([[GERD]]). These patients are usually older and have had [[GERD]] for a long time. Acid reflux can also be due to other causes, such as [[Zollinger-Ellison syndrome]], NG tube placement, and [[scleroderma]]. Other non-acid related causes of peptic strictures include infectious esophagitis, ingestion of chemical irritant, pill irritation, and radiation. Peptic stricture is a progressive mechanical dysphagia, meaning patients will complain of initial intolerance to solids followed by inability to tolerate liquids. Usually the threshold to solid intolerance is 13 mm of the esophageal lumen. Symptoms relating to the underlying cause of the stricture usually will also be present.
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| '''''[[Esophageal cancer]]''''' also presents with progressive mechanical dysphagia. Patients usually come with rapidly progressive dysphagia first with solids then with liquids, weight loss (> 10 kg), and anorexia (loss of appetite). Esophageal cancer usually affects the elderly. Esophageal cancers can be either squamous cell carcinoma or [[adenocarcinoma]]. [[Adenocarcinoma]] is the most prevalent in the US and is associated with patients with chronic GERD who has developed [[Barrett's esophagus]] (intestinal [[metaplasia]] of esophageal mucosa). Squamous cell carcinoma is more prevalent in Asia and is associated with tobacco smoking and alcohol use.
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| {{main|esophageal cancer}}
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| '''''Esophageal rings and [[esophageal web|web]]s''''', are actual rings and webs of tissue that may occlude the esophageal lumen.
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| * ''Rings'' --- Also known as [[Schatzki ring]]s from the discoverer, these rings are usually mucosal rings rather than muscular rings, and are located near the gastroesophageal junction at the squamo-columnar junction. Presence of multiple rings may suggest [[eosinophilic esophagitis]]. Rings cause intermittent mechanical dysphagia, meaning patients will usually present with transient discomfort and regurgitation while swallowing solids and then liquids, depending on the constriction of the ring.
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| * ''Webs'' --- Usually squamous mucosal protrusion into the esophageal lumen, especially anterior cervical esophagus behind the [[cricoid]] area. Patients are usually asymptomatic or have intermittent dysphagia. An important association of esophageal webs is to the [[Plummer-Vinson syndrome]] in [[iron deficiency]], in which case patients will also have anemia, koilonychia, fatigue, and other symptoms of [[anemia]].
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| {{main|esophageal web}}
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| '''''[[Achalasia]]''''' is an idiopathic motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation as well as loss of [[peristalsis]] in the distal esophagus, which is mostly smooth muscle. Both of these features impair the ability of the esophagus to empty contents into the stomach. Patients usually complain of dysphagia to both solids and liquids. Dysphagia to liquids, in particular, is a characteristic of achalasia. Other symptoms of achalasia include regurgitation, night coughing, chest pain, weight loss, and heartburn. The combination of achalasia, adrenal insufficiency, and alacrima (lack of tear production) in children is known as the triple A (Allgrove) syndrome. In most cases the cause is unknown (idiopathic), but in some regions of the world, achalasia can also be caused by [[Chagas disease]] due to infection by ''[[Trypanosoma cruzi]]''.
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| {{main|achalasia}}
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| '''''[[Scleroderma]]''''' is a disease characterized by [[atrophy]] and [[sclerosis]] of the gut wall, most commonly of the distal esophagus (~90%). Consequently, the lower esophageal sphincter cannot close and this can lead to severe gastroesophageal reflux disease (GERD). Patients typically present with progressive dysphagia to both solids and liquids secondary to motility problems or peptic stricture from acid reflux.
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| {{main|scleroderma}}
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| '''''Spastic motility disorders''''' include [[diffuse esophageal spasm]] (DES), [[nutcracker esophagus]], hypertensive lower esophageal sphincter, and nonspecific spastic esophageal motility disorders (NEMD).
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| * ''DES'' can be caused by many factors that affect muscular or neural functions, including acid reflux, stress, hot or cold food, or carbonated drinks. Patients present with intermittent dysphagia, chest pain, or heartburn.
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| '''''Rare causes of esophageal dysphagia not mentioned above'''''
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| * [[Diverticulum]]
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| * [[Aberrant subclavian artery]], or ([[Ortner's syndrome|dysphagia lusoria]])
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| * Cervical osteophytes
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| * [[Enlarged aorta]]
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| * [[Enlarged left atrium]]
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| * [[Mediastinal tumor]]
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| ===Diagnostic tools===
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| Once esophageal dysphagia has been implicated, the next step is either a ''[[barium swallow]]'' or an ''[[EGD|upper endoscopy]]''. If there is any suspicion of a proximal lesion such as:
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| * History of surgery for laryngeal or esophageal cancer
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| * History of radiation or irritating injury
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| * [[Achalasia]]
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| * [[Zenker's diverticulum]]
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| A barium swallow should be performed first instead of endoscopy to prevent any perforation. If [[achalasia]] suspected on barium swallow, [[manometry]] is performed next to confirm. If a stricture is suspected, endoscopy is performed. Any other lesions found are treated as such.
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| If there is no suspicion of any of the above, endoscopy can be performed first. Any structural or mucosal abnormality is treated. A normal endoscopy should be followed by manometry; and if manometry is also normal, the diagnosis is functional dysphagia.
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| ===Treatment===
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| The patient is generally sent for a GI, pulmonary, ENT, or oncology consult, depending on the suspected underlying cause. A consultation with a dietician may also be needed, as many patients may need dietary modifications.
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| ==See also==
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| * [[Swallowing]] | | * [[Swallowing]] |
| * [[Stroke]] | | * [[Stroke]] |
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| * [[Presbyphagia]] | | * [[Presbyphagia]] |
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| ==References==
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| {{Reflist|2}}
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| {{Symptoms and signs}}
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| {{Geriatrics}} | | {{Geriatrics}} |
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| [[Category:Geriatrics]] | | [[Category:Geriatrics]] |
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| [[de:Dysphagie]]
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| [[es:Disfagia]]
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| [[fr:Dysphagie]]
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| [[it:Disfagia]]
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| [[ms:Penyakit Disfagia]]
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| [[pt:Disfagia]]
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| [[fi:Dysfagia]]
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| [[ru:Дисфагия]]
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| [[pl:Dysfagia]]
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| [[Category:Symptoms]]
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| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
| [[Category:Otolaryngology]] | | [[Category:Otolaryngology]] |
| | [[Category:Symptoms]] |
| [[Category:Signs and symptoms]] | | [[Category:Signs and symptoms]] |
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| {{WH}}
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