Dysphagia refers to difficulty swallowing and can be caused by problems in the oral cavity, pharynx, or esophagus. It is important to determine the location and characteristics of the dysphagia through history and physical examination to guide diagnostic testing and identify potential underlying causes. Common causes of dysphagia include peptic strictures from acid reflux, eosinophilic esophagitis, esophageal rings or webs, esophageal cancer, and achalasia. Evaluation involves barium swallow, endoscopy with possible biopsy, and other tests as needed to diagnose the specific condition causing a patient's swallowing difficulties.

1. Dysphagia

2. Introduction
• The word dysphagia is derived from the Greek
words "dys" (with difficulty) and "phagia" (to
eat).
• Refers to problems with the transit of food or
liquid from the mouth to the hypopharynx or
through the esophagus.
• Severe dysphagia can compromise nutrition,
cause aspiration, and reduce quality of life

3. • Additional terminology pertaining to
swallowing dysfunction is as follows:
– The term "odynophagia" refers to pain with
swallowing.
– Aphagia -- complete esophageal obstruction ( a
food bolus or foreign body impaction.)

4. Classification
• Dysphagia can be classified as either
oropharyngeal or esophageal:
– Oropharyngeal dysphagia, also called transfer
dysphagia, arises from disorders that affect the
function of the oropharynx, larynx, and upper
esophageal sphincter.
• Neurogenic and myogenic disorders as well as
oropharyngeal tumors are the most common underlying
mechanisms for oropharyngeal dysphagia.
– Esophageal dysphagia arises within the body of the
esophagus, the lower esophageal sphincter, or cardia,
and is most commonly due to mechanical causes or a
motility disturbance.

5. Pathophysiology of Dysphagia
• Dysphagia can be subclassified both by location and by
the circumstances in which it occurs
• With respect to location, distinct considerations apply
to oral, pharyngeal, or esophageal dysphagia
• Dysphagia caused by an oversized bolus or a narrow
lumen is called structural dysphagia, whereas
dysphagia due to abnormalities of peristalsis or
impaired sphincter relaxation after swallowing is
called propulsive or motor dysphagia.
• More than one mechanism may be operative in a
patient with dysphagia

6. Oral and Pharyngeal (Oropharyngeal)
Dysphagia
• Oropharyngeal dysphagia may be due to neurologic,
muscular, structural, iatrogenic, infectious, and
metabolic causes.
• Iatrogenic, neurologic, and structural pathologies are
most common.
• Iatrogenic causes include surgery and radiation, often
in the setting of head and neck cancer.
• Neurogenic dysphagia resulting from cerebrovascular
accidents, Parkinson's disease, and amyotrophic lateral
sclerosis is a major source of morbidity related to
aspiration and malnutrition

7. Esophageal Dysphagia
• Circumferential lesions are more likely to cause
dysphagia than are lesions that involve only a
partial circumference of the esophageal wall.
• The most common structural causes of
dysphagia are Schatzki's rings, eosinophilic
esophagitis, and peptic strictures.
• Propulsive disorders leading to esophageal
dysphagia result from abnormalities of peristalsis
and/or deglutitive inhibition, potentially affecting
the cervical or thoracic esophagus.

8. Approach to the Patient: Dysphagia
History
• Dysphagia that localizes to the suprasternal notch
may indicate either an oropharyngeal or an
esophageal etiology as distal dysphagia is
referred proximally about 30% of the time.
• Dysphagia that localizes to the chest is
esophageal in origin.
• Nasal regurgitation and tracheobronchial
aspiration with swallowing are hallmarks of
oropharyngeal dysphagia or a tracheoesophageal
fistula

9. Hx …
• The type of food causing dysphagia is a crucial detail.
• Intermittent dysphagia that occurs only with solid food
implies structural dysphagia, whereas constant dysphagia
with both liquids and solids strongly suggests a motor
abnormality
• Dysphagia that is progressive over the course of weeks to
months raises concern for neoplasia.
• Episodic dysphagia to solids that is unchanged over years
indicates a benign disease process such as a Schatzki's ring
or eosinophilic esophagitis.
• Food impaction with a prolonged inability to pass an
ingested bolus even with ingestion of liquid is typical of a
structural dysphagia

10. Hx….
• A prolonged history of heartburn preceding the
onset of dysphagia is suggestive of peptic
stricture and, less commonly, esophageal
adenocarcinoma.
• A history of prolonged nasogastric intubation,
esophageal or head and neck surgery, ingestion
of caustic agents or pills, previous radiation or
chemotherapy, or associated mucocutaneous
diseases may help isolate the cause of dysphagia

11. • In patients with AIDS or other
immunocompromised states, esophagitis due
to opportunistic infections such as Candida,
herpes simplex virus, or cytomegalovirus and
to tumors such as Kaposi's sarcoma and
lymphoma should be considered.
• A strong history of atopy increases concerns
for eosinophilic esophagitis

12. Physical Examination
• The neck should be examined for thyromegaly.
• A careful inspection of the mouth and
pharynx should disclose lesions that may
interfere with passage of food.
• Physical examination is less helpful in the
evaluation of esophageal dysphagia as most
relevant pathology is restricted to the
esophagus.

13. Diagnostic Procedures
• Barium swallow
• Esophageal motility study.
• Endoscopy allows better visualization of
mucosal lesions than does barium radiography
and also allows one to obtain mucosal
biopsies.
• CT scan

14. DIFFERENTIAL DIAGNOSIS
• Peptic stricture
– Peptic stricture is a complication of acid reflux,
which occurs in approximately 10 percent of
patients with gastroesophageal reflux disease
(GERD)
• Eosinophilic esophagitis — Eosinophilic
esophagitis has emerged as an important
cause of dysphagia, particularly in adolescents
and young adults with environmental allergies
and a history of food impaction

15. • Esophageal rings and webs : are thin, fragile
structures that partially or completely
compromise the esophageal lumen.
– both chronic damage from gastroesophageal reflux
and a congenital or developmental origin have been
proposed
– First line of therapy for esophageal rings is dilation
with a large bougie
• Carcinoma — Cancer of the esophagus or gastric
cardia is often associated with anorexia,
significant weight loss, and rapidly progressive
dysphagia, initially for solids and later for liquids

16. • Radiation injury — Patients undergoing palliative
or radical radiotherapy for thoracic or head and
neck tumors are at risk for developing esophagitis
and esophageal strictures.
• Achalasia — Achalasia ( failure to relax) is a
disease of unknown cause in which there is a loss
of peristalsis in the distal esophagus and a failure
of LES relaxation.
– There will be dysphagia for both solids and liquids

17. • Functional dysphagia — Functional dysphagia
is a diagnosis of exclusion in patients with
dysphagia who have undergone a complete
diagnostic evaluation without evidence of a
structural abnormality or motility disturbance

18. Barium swallow showing a dilated
esophagus and birds beak appearance
typical of achalasia. Retained food is
also visible.

19. Endoscopic view of a Schatzki ring. The
ring appears as a thin membrane with
a concentric smooth contour that
projects into the lumen.

20. Esophageal adenocarcinoma at the
gastroesophageal junction