Dysphagia is the subjective sensation of difficulty swallowing Swallowing The act of taking solids and liquids into the gastrointestinal tract through the mouth and throat. Gastrointestinal Motility. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming “stuck.” Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Common causes of functional dysphagia include achalasia Achalasia Achalasia is a primary esophageal motility disorder that develops from the degeneration of the myenteric plexus. This condition results in impaired lower esophageal sphincter relaxation and absence of normal esophageal peristalsis. Patients typically present with dysphagia to solids and liquids along with regurgitation. Achalasia, scleroderma Scleroderma Scleroderma (systemic sclerosis) is an autoimmune condition characterized by diffuse collagen deposition and fibrosis. The clinical presentation varies from limited skin involvement to diffuse involvement of internal organs. Scleroderma, and diffuse esophageal spasm (DES). Mechanical causes of dysphagia include esophageal rings, webs, strictures, and cancer. Oropharyngeal dysphagia may be due to structural abnormalities or abnormal neuromuscular function and coordination Coordination Cerebellar Disorders. The diagnostic workup depends on the patient’s presenting symptoms, but may include manometry Manometry Measurement of the pressure or tension of liquids or gases with a manometer. Achalasia, barium esophagram, or direct visualization with nasopharyngeal laryngoscopy or endoscopy Endoscopy Procedures of applying endoscopes for disease diagnosis and treatment. Endoscopy involves passing an optical instrument through a small incision in the skin i.e., percutaneous; or through a natural orifice and along natural body pathways such as the digestive tract; and/or through an incision in the wall of a tubular structure or organ, i.e. Transluminal, to examine or perform surgery on the interior parts of the body. Gastroesophageal Reflux Disease (GERD). Treatment varies depending on the underlying cause.
Last updated: 10 Dec, 2021
Dysphagia is a condition in which there is a disruption of the swallowing Swallowing The act of taking solids and liquids into the gastrointestinal tract through the mouth and throat. Gastrointestinal Motility process, typically interfering with the ability to eat and drink.
Swallowing Swallowing The act of taking solids and liquids into the gastrointestinal tract through the mouth and throat. Gastrointestinal Motility consists of 3 phases:
Movement of a food bolus through the oral and pharyngeal phases of swallowing Swallowing The act of taking solids and liquids into the gastrointestinal tract through the mouth and throat. Gastrointestinal Motility
Image by Lecturio.There are 2 categories of dysphagia:
A barium swallow Barium Swallow Imaging of the Intestines study identifying a false diverticula arising from the posterior wall of the upper esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy, which is consistent with a Zenker’s diverticulum Diverticulum A pouch or sac opening from the colon. Diverticular Disease
Image: “Lateral X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests of a Zenker’s diverticula” by James Heilman, MD. License: CC BY-SA 4.0.Video fluoroscopic view in a patient who has undergone a near-total glossectomy Glossectomy Partial or total surgical excision of the tongue. Oral Cancer for advanced head and neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess cancer. The patient has poor oral bolus control and early loss into the oropharynx Oropharynx The middle portion of the pharynx that lies posterior to the mouth, inferior to the soft palate, and superior to the base of the tongue and epiglottis. It has a digestive function as food passes from the mouth into the oropharynx before entering esophagus. Pharynx: Anatomy (A, white arrows). He has lost the ability to pull the hyoid and the larynx Larynx The larynx, also commonly called the voice box, is a cylindrical space located in the neck at the level of the C3-C6 vertebrae. The major structures forming the framework of the larynx are the thyroid cartilage, cricoid cartilage, and epiglottis. The larynx serves to produce sound (phonation), conducts air to the trachea, and prevents large molecules from reaching the lungs. Larynx: Anatomy up and forward to open the upper esophageal sphincter Upper esophageal sphincter The structure at the pharyngoesophageal junction consisting chiefly of the cricopharyngeus muscle. It normally occludes the lumen of the esophagus, except during swallowing. Esophagus: Anatomy, resulting in pharyngeal dysphagia and food remaining in the pharynx Pharynx The pharynx is a component of the digestive system that lies posterior to the nasal cavity, oral cavity, and larynx. The pharynx can be divided into the oropharynx, nasopharynx, and laryngopharynx. Pharyngeal muscles play an integral role in vital processes such as breathing, swallowing, and speaking. Pharynx: Anatomy (B, white arrows) with penetration Penetration X-rays above the vocal folds (black arrows). This patient was determined to be at high risk of aspiration.
Image: “Lateral fluoroscopic view” by Caterina Giannitto. License: CC BY 4.0.Management is guided by the diagnostic workup, and is focused on improving food transfer and preventing aspiration:
Esophageal functional and motility Motility The motor activity of the gastrointestinal tract. Gastrointestinal Motility disorders typically occur due to pathology of the muscles of the esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy, causing a disruption in peristalsis Peristalsis A movement, caused by sequential muscle contraction, that pushes the contents of the intestines or other tubular organs in one direction. Gastrointestinal Motility. All functional and motility Motility The motor activity of the gastrointestinal tract. Gastrointestinal Motility disorders exhibit dysphagia with liquids and solids at the onset.
Overview of functional and motility Motility The motor activity of the gastrointestinal tract. Gastrointestinal Motility disorders
Image by Lecturio.An esophageal motility Esophageal Motility Gastrointestinal Motility disorder characterized by hyperdynamic and non-propulsive contractions:
Diffuse esophageal spasm: barium esophagram showing the typical “corkscrew” pattern
Image: “Smooth short stricture Stricture Primary Sclerosing Cholangitis in the distal esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy” by Chui Man Carmen Hui et al AL Amyloidosis. License: CC BY 4.0.Manometry Manometry Measurement of the pressure or tension of liquids or gases with a manometer. Achalasia findings in esophageal motility Esophageal Motility Gastrointestinal Motility disorders
Image by Lecturio.Scleroderma Scleroderma Scleroderma (systemic sclerosis) is an autoimmune condition characterized by diffuse collagen deposition and fibrosis. The clinical presentation varies from limited skin involvement to diffuse involvement of internal organs. Scleroderma is an autoimmune disorder Autoimmune Disorder Septic Arthritis that can cause atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation and sclerosis Sclerosis A pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve. Wilms Tumor of the distal esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy, resulting in diminished (or absent) peristalsis Peristalsis A movement, caused by sequential muscle contraction, that pushes the contents of the intestines or other tubular organs in one direction. Gastrointestinal Motility and LES pressure.
A: upper endoscopy Endoscopy Procedures of applying endoscopes for disease diagnosis and treatment. Endoscopy involves passing an optical instrument through a small incision in the skin i.e., percutaneous; or through a natural orifice and along natural body pathways such as the digestive tract; and/or through an incision in the wall of a tubular structure or organ, i.e. Transluminal, to examine or perform surgery on the interior parts of the body. Gastroesophageal Reflux Disease (GERD) demonstrating reflux esophagitis Esophagitis Esophagitis is the inflammation or irritation of the esophagus. The major types of esophagitis are medication-induced, infectious, eosinophilic, corrosive, and acid reflux. Patients typically present with odynophagia, dysphagia, and retrosternal chest pain. Esophagitis; B: upper endoscopy Endoscopy Procedures of applying endoscopes for disease diagnosis and treatment. Endoscopy involves passing an optical instrument through a small incision in the skin i.e., percutaneous; or through a natural orifice and along natural body pathways such as the digestive tract; and/or through an incision in the wall of a tubular structure or organ, i.e. Transluminal, to examine or perform surgery on the interior parts of the body. Gastroesophageal Reflux Disease (GERD) demonstrating an esophageal stricture Stricture Primary Sclerosing Cholangitis in a patient with scleroderma Scleroderma Scleroderma (systemic sclerosis) is an autoimmune condition characterized by diffuse collagen deposition and fibrosis. The clinical presentation varies from limited skin involvement to diffuse involvement of internal organs. Scleroderma
Image: “EGD in systemic sclerosis Systemic sclerosis Scleroderma (systemic sclerosis) is an autoimmune condition characterized by diffuse collagen deposition and fibrosis. The clinical presentation varies from limited skin involvement to diffuse involvement of internal organs. Scleroderma” by the Postgraduate Department of Dermatology, STDs & Leprosy Leprosy Leprosy, also known as Hansen’s disease, is a chronic bacterial infection caused by Mycobacterium leprae complex bacteria. Symptoms primarily affect the skin and peripheral nerves, resulting in cutaneous manifestations (e.g., hypopigmented macules) and neurologic manifestations (e.g., loss of sensation). Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India. License: CC BY 4.0.A neurogenic esophageal motility Esophageal Motility Gastrointestinal Motility disorder resulting in impaired LES relaxation and diminished peristalsis Peristalsis A movement, caused by sequential muscle contraction, that pushes the contents of the intestines or other tubular organs in one direction. Gastrointestinal Motility:
Achalasia Achalasia Achalasia is a primary esophageal motility disorder that develops from the degeneration of the myenteric plexus. This condition results in impaired lower esophageal sphincter relaxation and absence of normal esophageal peristalsis. Patients typically present with dysphagia to solids and liquids along with regurgitation. Achalasia: “bird’s beak” appearance on a barium esophagram
Image: “ Barium swallow Barium Swallow Imaging of the Intestines” by the Department of Internal Medicine, Nashville, TN, USA. License: CC BY 4.0.Achalasia Achalasia Achalasia is a primary esophageal motility disorder that develops from the degeneration of the myenteric plexus. This condition results in impaired lower esophageal sphincter relaxation and absence of normal esophageal peristalsis. Patients typically present with dysphagia to solids and liquids along with regurgitation. Achalasia: manometry Manometry Measurement of the pressure or tension of liquids or gases with a manometer. Achalasia showing high LES pressure (top line)
Image by Lecturio.Esophageal mechanical and obstructive disorders typically occur due to obstruction of the esophageal lumen. All mechanical and obstructive disorders exhibit dysphagia with solids with progression to liquids.
Rings and webs are thin mucosal strictures that partially occlude the esophageal lumen:
Barium esophagram showing esophageal webs in the upper esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy
Image: “ Barium swallow Barium Swallow Imaging of the Intestines examination” by Usha Dutta et al AL Amyloidosis. License: CC BY 2.0.An esophageal stricture Stricture Primary Sclerosing Cholangitis is an abnormal narrowing of the esophageal lumen:
Barium esophagram demonstrating an esophageal stricture Stricture Primary Sclerosing Cholangitis (arrow), which shows a stricture Stricture Primary Sclerosing Cholangitis in the proximal esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy, but strictures will usually be in the distal esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy
Image: “Barium esophagogram” by the Division of Pediatric Gastroenterology, Children’s Hospital, King Fahad Medical City, P. O. Box 59046, Riyadh, 11525, Kingdom of Saudi Arabia. License: CC BY 4.0.Endoscopy Endoscopy Procedures of applying endoscopes for disease diagnosis and treatment. Endoscopy involves passing an optical instrument through a small incision in the skin i.e., percutaneous; or through a natural orifice and along natural body pathways such as the digestive tract; and/or through an incision in the wall of a tubular structure or organ, i.e. Transluminal, to examine or perform surgery on the interior parts of the body. Gastroesophageal Reflux Disease (GERD) image showing a significant esophageal stricture Stricture Primary Sclerosing Cholangitis
Image: “Esophagogastroduodenoscopy” by the Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan. License: CC BY 4.0.Esophagogastroduodenoscopy (EGD) showing cancer outgrowth (SCC), causing a narrowing of the lumen
Image: “A Late-Stage Squamous Cell Carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC)” by Brooks PJ, Enoch M-A, Goldman D, Li T-K, Yokoyama A. License: C BY 2.5.