Updated: 6/14/2019

Dysphagia/Odynophagia

Topic
Review Topic
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Snapshot
  • A 44-year-old woman with a medical history of scleroderma presents to her rheumatologist with increasing dysphagia. She was diagnosed with systemic sclerosis 1 year ago and has had 1 episode of hypertensive renal crisis secondary to the disease. Over the past few weeks, however, she reports having increasing dysphagia. She was also recently diagnosed with aspiration pneumonia and treated with a full course of antibiotics. She denies any nausea or vomiting but reports dysphagia with both liquid and solid food. Physical exam is unremarkable. She is scheduled for an upper endoscopy. (Scleroderma-induced esophageal dysmotility)
Introduction
  • Clinical definition
    • dysphagia
      • difficulty swallowing
      • often categorized by location
        • oropharyngeal dysphagia
        • esophageal dysphagia
    • odynophagia
      • pain with swallowing
  • Epidemiology
    • demographics
      • common in patients in long-term care facilities
      • elderly patients
  • Treatment
    • treat underlying cause
  • Complications
    • malnutrition
    • aspiration pneumonia
Dysphagia
  • Esophageal dysphagia
    • pathogenesis
      • obstruction vs dysmotility
      • primary (e.g., esophageal spasm or achalasia)
      • secondary (e.g., systemic disease, such as scleroderma)
    • presentation
      • dysphagia
      • sensation of food being stuck in throat
      • chest pain
        • burning or heavy
      • regurgitation
        • seen more with dysmotility issues
  • Oropharyngeal dysphagia
    • pathogenesis
      • usually functional etiology
        • neurological or muscular dysfunction
    • presentation
      • dysphagia
      • delayed initiation of swallow
      • aspiration
        • coughing
        • choking
      • need to swallow repeatedly for passage of food
      • regurgitation of fluid through nose during swallowing
  • Treatment
    • treat underlying etiology
    • percutaneous endoscopic gastrostomy (PEG) tube
      • indication
        • for severe cases or prolonged dysphagia
    • dietary changes
      • indication
        • patients who are unable to tolerate oral medications or solid foods
        • patients may require a soft or liquid diet
 
 
Dysphagia
Clinical Features
  Esophageal Dysphagia
Oropharyngeal Dysphagia
Pathogenesis
  • Obstruction
  • Dysmotility
  • Neurologic
  • Muscular
Food type
  • Solids > liquids
  • Liquids and solids
  • Liquids > solids
Symptoms
  • Progressive dysphagia
  • Dysphagia
  • Sensation of food stuck in throat
  • Choking
  • Regurgitation of food through nose
  • Aspiration
Etiologies
  • Strictures
    • infectious esophagitis 
    • radiation-induced strictures
  • Esophageal webs
  • Esophageal carcinoma
  • Schatzki rings
  • Achalasia
  • Connective tissue disorders
    • Sjogren syndrome
    • scleroderma
  • Esophageal spasms
  • Nutcracker esophagus
  • Stroke
  • Parkinson disease
  • Myasthenia gravis
  • Head trauma
  • Multiple sclerosis
  • Myopathies
  • Obstructive causes (rare)
    • Zenker diverticula
    • Plummer-Vinson syndrome
    • malignancy
Diagnostic Imaging
Type Upper Endoscopy Esophageal Manometry Barium Swallow Study
Indication
  • All patients
  • Often the initial imaging
  • Endoscopy results are equivocal
  • Barium swallow is equivocal
  • Dysphagia to solids and liquids or suspicion for dysmotility
  • History of radiation, injury, or strictures
  • Endoscopy results are equivocal
  • Dysphagia to solids alone
Findings
  • Esophagitis
  • Dysmotility
  • Strictures
  • Masses
  • Diverticulum
  • Rings or webs
  • Achalasia (abnormal relaxation of lower esophageal sphincter (LES) and absent distal peristalsis)
  • Diffuse esophageal spasms (incomplete LES sphincter relaxation and progressive peristalsis)
  • Scleroderma (absence of all peristalsis)
  • Achalasia (bird beak apperance)
  • Diffuse esophageal spasm (corkscrew esophagus)
  • Strictures
  • Rings or webs
  • Masses
 
Odynophagia
  • Introduction
    • often associated with dysphagia
  • Epidemiology
    • risk factors
      • very hot or cold food
      • immunocompromised
  • Etiology
    • infectious esophagitis
      • Candida (dysphagia > odynophagia)
      • HSV or CMV ulcerative esophagitis (odynophagia > dysphagia)
    • medication-induced esophagitis
    • ulcers
    • malignancy
  • Presentation
    • pain with swallowing
    • no sensation of food boluses being stuck in the throat
  • Diagnosis
    • imaging
      • upper endoscopy
        • findings
          • ulcers
          • esophagitis
          • malignancy
  • Treatment
    • treat underlying cause
 

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