Dysphagia is a common symptom that requires early evaluation to determine if it is caused by issues in the oropharynx or esophagus. A thorough history and physical exam can identify 80-85% of causes, while tests like modified barium swallow, endoscopy, and manometry provide further information. Treatment depends on the underlying problem, such as dilation for strictures, surgery for obstructions, or lifestyle/medication changes for conditions like GERD. Early diagnosis and treatment can help address dysphagia's underlying cause.

1. Approach to dysphagia
Dr MOHAMMAD RUHUL AMIN
REGISTRAR
GASTROENTEROLOGY
JRRMCH

2. definition
 dysphagia:
difficulty in swallowing
 odynophagia:
painful swallowing
 Globus:
constant sensation of a lump in the throat -
no organic defect.

3. epidemiology
 a number of disorders can cause dysphagia-
both benign and malignant,
 involve either the oropharynx or the esophagus,
 can be associated with multiple systemic
disorders

4. Epidemiology
 a very common condition encountered in clinical
practice; affects-
1.6 – 15% of the middle-aged and
13 – 35% of the elderly populations.
1. Lindgren S, Janzon L. Dysphagia. 1991;6:187-192.
2. Chen CL, Orr WC. Dysphagia. 2005;20:261-265.
3. Achem SR, Devault KR. J Clin Gastroenterol. 2005;39:357-371.

5. Anatomy and physiology
of deglutition
deglutition:
 swallowing-food / fluid :mouth - stomach
 voluntary & involuntary neuromuscular
contractions
 oropharyngeal & oesophageal stages

6. oropharyngeal stage:
 tongue/muscles of mastication/saliva- from
anterior oral cavity to oropharynx,
involuntary reflexes- V, VII, XII, cerebellum
 soft palate closes nasopharynx, suprahyoid pulls
larynx up-forward, epiglottis closes airway,
striated pharyngeal muscles- pushes to pass
cricopharyngeous- IX, X
Anatomy and physiology
of deglutition

7. oesophageal stage:
 proximal oesophagus - skeletal muscles,
involuntary forces down to stomach-
medulla
Anatomy and physiology
of deglutition

8. Pathophysiology of
oro-pharyngeal dysphagia
 striated muscles of mouth, pharynx , upper
oesophageal sphincter affected - mostly in the
elderly
 - inability to initiate a swallow,
- failure of bolus transfer from the mouth
to the esophagus.
this condition may result from a variety of
neurologic and muscular abnormalities.

9. pathophysiology of oesophageal
dysphagia
 difficulty in transporting ingested material down
the esophagus -
- mechanical problem
- disordered peristalsis /motility
this condition can result from either
- intrinsic causes - obstruct luminal flow
- extrinsic causes - wall compression
- motor disorders

10. what should be the approach when
a patient comes with dysphagia ?

11. Q. do solid/liquid/both elicites dysphagia ?
- solids – mechanical : intrinsic/extrinsic
- both liq/solid - very onset : motility disorders
Q. what is the course of dyaphagia -
- acute : food impaction, ulcers
- sudden : CVA
- progressive/long duration : strictures / malignancy
- non - progressive/intermittent : rings
history taking:

12. History taking
Q. what is the duration of the dysphagia?
short progressive history - malignancy
Q. whether can localize the site?
accurately locate - oropharyngeal cause,
oeso - can’t localize,
some can point it at xiphoid.

13. History - evaluation
Q. whether has any additional symptoms ?
heart burn, regurgitation, aspiration, weight loss,
chest / abdominal pain
- chronic heart burn : erosive oesophagitis
/stricture
- cough/wheeze/sleep disruption -
GERD, or achalasia- if also chest pain

14. History taking
 Q. whether has any additional symptoms ?
food sticking at throat / inability to chew /
choking - neurologic disease
- pain during swallowing : malignancy/infection/
inflammation from corrosive agents
- weight loss - malignancy/ achalasia

15. History -evaluation
Q. does the patient have any comorbidities?
- scleroderma / SLE – dysphagia
Q. What medication does the patient take?
- chronic immunosuppressives -
infectious oesophagitis (fungal/viral),
dysphagia, as well as odynophagia
-

16. Q. What medication does the patient take?
- centrally acting drugs-tardive dyskinesia
- NSAID’s/ tetracycline/iron/K/vit-c-
oesophagitis/ulcers -
mid or distal oesophagus - strictures even.
History -evaluation

17. Physical examination
 general exam-
- eye, buccal cavity /v.cord/soft palate/nasopharynx,
- head - neck region - fo lymp nodes, masses, signs of
prior surgery, radiotherapy, thyroid - mass or
thyrotoxicosis, any tremor
 HPF
 cranial nerves –
motor & sensory of V,VII,IX,X, & motor of XII,
 deep tendon reflexes; cerebellar exam

18.  focusd organ specific /symptoms specific exam.
- chest - signs of pneumonia - aspiration - OPD
- abdomen - organomegaly, masses
- joints - collagen vascular disease
Physical examination

19. Laboratory evaluation
good history & detailed exam - correct diagnosis: 80
- 85% cases, atypical symptoms/signs -detailed
evaluation
tests will depend on -
 OPD or ED; structural or motility disorder
 OPD -
- modified Ba - swallow (MBS) - pharyngeal swallow
- endoscopic swallow exam (FEES) - vocal cord or
airway closure
 ED - EGD, then motiloity, manometry etc.

20. Lab evaluation
 Ba - swallow :
roadmap to endoscopy
if proximal stricture suspected -
caustic ingestion/radiation/ larynx surgery
 Endoscopy - initial test, except achalasia/OPD,
gold - standard-anatomic lesion/tissue collection

21.  oesophageal manometry
- mechanical problem excluded
- achalasia/motility disorders suspected
 high - resolution intra-luminal USG - to identify
oesophageal muscle abnormality
 CT
Lab evaluation -others

22. differential diagnosis of dysphagia

23. etiology of OPD
neurologic structural others
CVA
Parkinson’s
MS, polio,
neoplasm,
Alzheimer’s,
pharyngitis,
TB,abscess,
P-V syndrome,
diverticulum,
compression,
corrosives,
radiation
hyperthyroidism,
sarcoidosis,
SLE,
diphtheria,
herpes,
myasthenia,
myositis

24. etiology of esophageal dyspagia
structural
(intrinsic)
structural
(extrinsic)
neuromuscular
disorders
peptic stricture,
neoplasm,
FB impaction,
pill injury,
ring/web/diverti
cula,
mediastinal
mass,
vascular
compression,
achalasia,
diffuse
oesophageal
spasm,
GERD,
scleroderma,

25. Treatment
upon underlying abnormalities
 stroke -
- re - training/ physiotherapy
- permanently impaired - feeding gastrostomy,
 thyrotoxicosis - specific Rx - 3 weeks to improve,
 achalasia - pneumatic dilatation /surgery/
botulinium
 scleroderma/GERD-aggressive PPI / dilatation

26.  web /ring/ benign stricture – dilatation & PPI
 diverticulum - surgery
 pemphigous - steroids
 caustics/ radiation- intralesional steroid &
dilatation
 refractory stricture/ malignancy - stent
placement
Treatment

27. treatment
 squamous cell ca - surgery
 inoperable -radio/chemo/PDT
 dysphagia due to external compression - stent
placement

28. Summary
 dysphagia – a common symptom, &
now considered as alarm symptom.
 needs early evaluation
 to differentiate between OPD & ED
 ED - most cases EGD to be done for evaluation
 treatment depends on underlying
pathophysiology