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 DysphagiaClinical FeaturesEsophageal DysphagiaOropharyngeal DysphagiaPathogenesisObstructionDysmotilityNeurologicMuscularFood typeSolids > liquidsLiquids and solidsLiquids > solidsSymptomsProgressive dysphagiaDysphagiaSensation of food stuck in throatChokingRegurgitation of food through noseAspirationEtiologiesStricturesinfectious esophagitisradiation-induced stricturesEsophageal websEsophageal carcinomaSchatzki ringsAchalasiaConnective tissue disordersSjogren syndromesclerodermaEsophageal spasmsNutcracker esophagusStrokeParkinson diseaseMyasthenia gravisHead traumaMultiple sclerosisMyopathiesObstructive causes (rare)Zenker diverticulaPlummer-Vinson syndromemalignancyDiagnostic ImagingTypeUpper EndoscopyEsophageal ManometryBarium Swallow StudyIndicationAll patientsOften the initial imagingEndoscopy results are equivocalBarium swallow is equivocalDysphagia to solids and liquids or suspicion for dysmotilityHistory of radiation, injury, or stricturesEndoscopy results are equivocalDysphagia tosolids aloneFindingsEsophagitisDysmotilityStricturesMassesDiverticulumRings or websAchalasia (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)StricturesRings or websMasses 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