Chapter 35

Dysphagia
Anthony Lembo, MD, and Filippo Cremonini, MD

Case Scenario
A 52-year-old gentleman comes to your office with a history • Would you classify his dysphagia as esophageal or
of intermittent difficulty swallowing solid food. His symp- oropharyngeal?
toms have been present for the past 5 years. He points to his • What symptoms help determine whether his
supraclavicular notch when describing where the food feels dysphagia is due to a mechanical or motor (ie,
stuck, although he is able to chew his food and transfer it into motility) abnormality?
his posterior pharynx without difficulty. He does not choke
• How can you use the patient’s history to
or cough while eating. Drinking water will usually relieve
distinguish between a benign and malignant cause
his symptoms, although on several occasions he has self-­
of his dysphagia?
induced vomiting. His symptoms are slightly worse now than
they were several years ago, which prompted today’s visit.

INTRODUCTION Dysphagia can be classified as either oropharyngeal or

The word dysphagia derives from the Greek words dys (with
difficulty) and phagein (to eat) and is defined as difficulty in
swallowing. It is the sensation of hesitation or delay in pas-
sage of food during swallowing. Therefore, dysphagia differs
from odynophagia, which refers to pain with swallowing. It
also differs from globus, which is the sensation of a lump or
tightness in the throat unrelated to swallowing. The complaint
of dysphagia, especially when it is a new symptom, should
always be taken seriously because it is the most common pre-
senting symptom of neoplasm of the esophagus.
esophageal.1 These are distinct processes that require differ-
ent evaluation and management. Oropharyngeal (or transfer)
dysphagia occurs from disorders that affect the oropharyngeal
area, typically from neurologic or myogenic abnormalities as
well as oropharyngeal tumors. Esophageal dysphagia occurs
from disorders of the esophagus and is most commonly due to
mechanical obstruction or altered motility of the esophagus.
A detailed history can distinguish between the 2 types of dys-
phagia and with further evaluation can establish the diagnosis
in 80% to 85% of cases.2

KEY TERMS
  Esophageal dysphagia Difficulty in passage of a bolus from the upper esophagus to the stomach.
  Globus Sensation of lump or tightness in the throat unrelated to swallowing.
  Mechanical disorder Obstruction of the esophageal lumen.
  Motor disorder of the esophagus Dyscoordination of the esophageal contractions.
  Odynophagia Pain with swallowing.
  Oropharyngeal dysphagia Difficulty initiating the swallowing process (ie, passage of a bolus from the
mouth to the proximal esophagus).

353
354 Section VII  Gastrointestinal System

ETIOLOGY
The exact prevalence of dysphagia is unknown. Current stud-
ies estimate the prevalence of dysphagia to be between 16%
and 22% among individuals over 50 years of age.3 The esti-
mated prevalence of dysphagia in younger people is lower. For
example, in a population survey of persons age 30 to 64 years
living in the Midwest, the prevalence of dysphagia was 6% to
9%.4 Up to 25% of hospitalized patients and 33% of nursing
home residents experience dysphagia.5 Most nursing home
residents with dysphagia have oropharyngeal dysphagia.6
Oropharyngeal dysphagia complicates up to 67% of strokes
and places these patients at increased risk for aspiration pneu-
monia. The 12-month mortality rate in these persons is as high
as 45%.7
A study at the Mayo Clinic showed that of 499 patients
with esophageal dysphagia, 47% had an obstructive lesion in
the esophagus (eg, ring, web, stricture, cancer), 32% had dys-
phagia related to disturbed esophageal motility (eg, spasm,
scleroderma, achalasia), and 21% had no demonstrable struc-
tural or motor abnormalities in the esophagus or oropharynx.
Older age, male sex, the presence of weight loss, heartburn,
and a history of prior esophageal dilation significantly pre-
dicted mechanical causes of dysphagia.8
Eosinophilic esophagitis (EE) is increasing recognized
as a cause of dysphagia in the pediatric as well as the adult
population. EE can result in narrowing and stricturing of the
esophagus and is a common cause for food impaction, espe-
cially in young adults. EE is diagnosed by the presence of 15
eosinophils per high-power field on light microscopy. Recent
data suggest that dilatation of the esophagus in patients with
EE is associated with increased rate of esophageal perfora-
tion. The treatment is avoidance of dietary allergens, topical
steroids, and anti–interleukin-5 antibody if necessary.

Differential Diagnosis
Oropharyngeal dysphagia Examples
Neuromuscular causes Stroke
Cerebral palsy
Multiple sclerosis
Myasthenia gravis
Amyotrophic lateral sclerosis
Parkinson’s disease
Myopathies
Polymyositis/dermatomyositis
Structural causes Zenker diverticulum
Head and neck tumors
Cervical spondylosis
Vertebral osteophytes
Pharyngeal webs (Plummer-Vinson syndrome)
Iatrogenic causes Radiation therapy
Corrosive pill injury
Anticholinergic medications (dries mucous membranes)
Esophageal dysphagia Examples
Motor disorders Achalasia
Diffuse esophageal spasm
Nutcracker esophagus
 Chapter 35  Dysphagia 355

Scleroderma
Sjögren syndrome
Chagas disease
Mechanical, intrinsic Tumors (esophageal carcinoma, lymphoma)
Strictures
Lower esophageal rings (Schatzki ring)
Esophageal webs and rings
Eosinophilic (allergic) esophagitis (EE)
Foreign bodies
Mechanical, extrinsic Right-sided aorta
Left atrial enlargement
Aberrant vessels
Mediastinal lymphadenopathy
Substernal thyroid
Iatrogenic Pill esophagitis (doxycycline, nonsteroidal anti-inflammatory drugs
[NSAIDs], alendronate, potassium chloride tablets)
Infectious Candidal esophagitis
Herpes esophagitis
Cytomegalovirus (CMV) esophagitis

GETTING STARTED WITH THE HISTORY

• Ask the patient to describe what happens when he or she
swallows.
• Ask open-ended questions.
• Distinguish between oropharyngeal and esophageal
dysphagia, remembering that in up to 80% of cases of
dysphagia, it is possible to establish the cause based on
history alone.
• Determine which types of food result in dysphagia
(solids, liquids, or both). Dysphagia to both solids and
liquids is suggestive of a motor disorder, whereas dys-
phagia to solids alone is more likely due to a mechanical
obstruction.
• Determine the time course. The new onset of symptoms
that progressively worsen over weeks to months requires
prompt evaluation because of the concern for malignancy.

Questions
Tell me what happens when you swallow.
When did you first notice that you were having difficulty
swallowing? Are your symptoms getting worse?
Describe what happens when you try to eat solid foods.
Describe what happens when you drink liquids.
Remember
Avoid interrupting.
Do not ask focused questions until the patient is
done describing his or her symptoms in detail.
Ask the patient to describe these events in detail.
356 Section VII  Gastrointestinal System

INTERVIEW FRAMEWORK • Assess for additional alarm symptoms (ie, weight loss,
bleeding, fevers, hematemesis, advanced age).
• Evaluate the patient’s medication list before the • Establish characteristic features of the dysphagia such
interview and consider the potential contribution of the as onset, duration, frequency, location, and precipitat-
medications in dysphagia. ing or alleviating factors. If a patient has not offered this
• Determine whether the patient has symptoms with information with your open-ended questioning, be sure
ingestion of solids only or both liquids and solids to dis- to ask directed questions.
tinguish between mechanical obstruction and neuromus-
cular disorders.
• Determine whether symptoms are progressive or IDENTIFYING ALARM SYMPTOMS
intermittent.
• Older patients presenting with progressive dysphagia,
• Determine whether the patient has any associated symp- particularly those with a past history of alcohol abuse,
toms or comorbid conditions, such as history of stroke, smoking, obesity, or gastroesophageal reflux, should
neurologic disorders, tobacco use, or history of reflux raise concern about an underlying oropharyngeal or
disease. esophageal malignancy.

Serious Diagnoses
Diagnosis Remarks Prevalence
Oropharyngeal Associated with tobacco and chronic alcohol use. 82% of all patients with
or laryngeal oropharyngeal or laryngeal
carcinoma carcinoma experience dysphagia.9
Stroke Most common cause of oropharyngeal dysphagia. 45% of all stroke patients experience
Onset is often abrupt. dysphagia at 3 months.
Head injury
Parkinson’s disease Common cause of oropharyngeal dysphagia. 81% of patients with Parkinson’s
disease have mild dysphagia.
Multiple sclerosis 24%–34% of patients with multiple
sclerosis have permanent
dysphagia.10

Amyotrophic lateral Characterized by progressive dysphagia.

sclerosis
Huntington’s chorea
Myasthenia gravis
Esophageal
carcinoma
Mediastinal tumors
Vascular structures
(dysphagia lusoria)
Muscular dystrophies
Dysphagia becomes progressively worse with 67% of patients have dysphagia at
repetitive swallows. the time of diagnosis.
Progressive dysphagia to solids, and then to 6%–17% of patients presenting with
both solids and liquids, is the most common dysphagia in the primary care
presentation. Squamous cancer of the esophagus setting prove to have carcinoma.
is associated with smoking and alcohol use.
Adenocarcinoma of the esophagus is associated
with gastroesophageal reflux, smoking, and
obesity.
Can present with dysphagia and ptosis later in life.
 Chapter 35  Dysphagia 357

If Present, Consider Serious However, Benign Causes for This

Alarm Symptoms Causes… Feature Include…
Weight loss Malignancy Peptic stricture
Progressive symptoms Malignancy
Neurodegenerative disorders
Symptoms are worse with Malignancy Peptic stricture
solids than with liquids
Esophageal web or ring
Foreign bodies
Blood in stools Malignancy
Otalgia (ear pain) with Hypopharyngeal lesion (eg,
dysphagia squamous cell cancer or thyroid
cancer)

Hoarseness (dysphonia) or Muscular dystrophies

pain with speaking and
dysphagia
Dysarthria Stroke

FOCUSED QUESTIONS
After hearing the story in the patient’s own words and consid-
ering possible alarm symptoms, ask the following questions to
narrow the differential diagnosis.

Q uestions T H I N K A B O U T. . .
Do you cough, choke, or sense food coming back through Oropharyngeal dysphagia
your nose after swallowing?
Does it feel as if food is getting stuck within the first few Oropharyngeal dysphagia
seconds of swallowing?
Do you have difficulty swallowing liquids, solids, or both? Liquids and solids = motor disorder
Solids progressing to include liquids =
mechanical obstruction
Are your symptoms getting worse? Rapidly progressive symptoms are worrisome
for malignancy
Do you always have trouble swallowing, or are your Intermittent, nonprogressive symptoms suggest a
symptoms intermittent? distal esophageal web or ring
Have you received radiation therapy in the past? Radiation esophagitis
Do you take your medications with fluids? Pill esophagitis. Most commonly associated
with ingestion of iron supplements, aspirin,
Do you take your medications immediately before going to bed?
potassium, doxycycline, and alendronate.
Do you have a medical condition that suppresses your Candidal, herpes simplex virus (HSV), or CMV
immune system (eg, human immunodeficiency virus [HIV], esophagitis
chronic steroid use, chemotherapy)?
—Continued next page
358 Section VII  Gastrointestinal System

Continued—

Quality
Is food sticking or getting stuck after you swallow? Esophageal dysphagia
Have you experienced nasal regurgitation? Oropharyngeal dysphagia
Do you have difficulty initiating a swallow? Oropharyngeal dysphagia
Do you choke or cough when you try to swallow? Oropharyngeal dysphagia
Have your symptoms remained the same over a long period Nonprogressive symptoms indicate benign
of time, or are they getting worse? structural lesions such as Schatzki ring or web
Location
Where exactly does the food stick or hang up? Oropharyngeal dysphagia: Patients frequently
point to their cervical region
Esophageal dysphagia: The lesion is at or below
the region to which they point
Time course and frequency
Are your symptoms episodic? Episodic dysphagia to solids over a long period
of time suggests a benign disease such as a lower
esophageal ring
How long have you had these symptoms? Dysphagia of short duration suggests an
inflammatory process

Associated symptoms
Do you hear a gurgling noise when you swallow? Zenker diverticulum
Do you feel like you have bad breath? Halitosis is associated with Zenker diverticulum
Do you regurgitate old foods? Distal esophageal obstruction
Zenker diverticulum
Achalasia
Is it painful to swallow? Esophageal mucosal inflammation (ie,
esophagitis)
Do you experience chest pain? Motor disorders of the esophagus (ie, diffuse
esophageal spasm, achalasia, and scleroderma)
Do you ever have to bear down or raise your arms over your Motor disorders
head to help a food bolus pass?
Are your symptoms worse with very hot or cold liquids? Motor disorders
Do you have a long-standing history of heartburn? Peptic stricture
Are your symptoms relieved by repeated swallows? Motor disorders
Have you ever experienced the sudden onset of dysphagia Esophageal ring
after swallowing pieces of meat?
“Steak house syndrome” (Recurrent episodes of
obstruction in distal esophagus often after eating
a piece of steak or bread. The obstruction is the
result of a lower esophageal ring and is usually
relieved by drinking large amounts of water.)
 Chapter 35  Dysphagia 359

Are your symptoms worse when you swallow cold foods? Motor disorders

Do you suffer from food allergies or have other allergic EE

diseases (eg, asthma)?

DIAGNOSTIC APPROACH (INCLUDING ALGORITHM)

The diagnostic approach algorithm for dysphagia is shown in
Figure 35–1.

Dysphagia

Difficulty initiating
Food stops or
swallow (symptoms include
“sticks” after
choking, coughing, nasal
swallowing
regurgitation)

Oropharyngeal dysphagia Esophageal dysphagia

Solid foods only Solid and liquids

Mechanical Neuromuscular
obstruction disorder

Intermittent Progressive Intermittent Progressive

Chronic Chronic Respiratory

Age > 50 Chest pain
heartburn heartburn symptoms

Lower Diffuse
Peptic
esophageal Carcinoma esophageal Scleroderma Achalasia
stricture
ring spasm

Figure 35–1  Diagnostic approach: Dysphagia.

CAVEATS • Distinguish between oropharyngeal and esophageal

dysphagia at the beginning of the interview.
• Dysphagia should always be taken seriously and should • Patients with dysphagia due to esophageal disease, such
prompt further evaluation. Dysphagia is never functional as a peptic stricture, often perceive the obstruction to be in
and always mandates a careful evaluation. the suprasternal notch even though the obstruction is distal.
• The duration and frequency of a patient’s dysphagia • Dysphagia in young persons (men > women) may be
provide useful clues and can help make the secondary to EE, especially in patients with disorders
diagnosis. such as asthma and atopic dermatitis.
360 Section VII  Gastrointestinal System
• Dysphagia to solid food is most often due to a mechani-
cal obstruction, whereas dysphagia to solid and liquid
food is often due to a motor (motility) disorder.
• Dysphagia can occur from impingement of the esopha-
gus by a vascular anomaly (dysphagia lusoria) such as
an aberrant right subclavian artery.
• A history of dry mouth or eyes may indicate in-
adequate salivary production. In such cases, it is
particularly important to obtain a detailed review of
medications. Anticholinergics, antihistamines, and
certain antihypertensives can reduce salivary flow.
Consider Sjögren syndrome when these sicca symp-
toms are present.
Case Scenario | Resolution
A 52-year-old gentleman comes to your office with a history
of intermittent difficulty swallowing solid food. His symp-
toms have been present for the past 5 years. He points to
his supraclavicular notch when describing where the food
feels stuck, although he is able to chew his food and trans-
fer it into his posterior pharynx without difficulty. He does
not choke or cough while eating. Drinking water will usu-
ally relieve his symptoms, although on several occasions he
has self-induced vomiting. His symptoms are slightly worse
now than they were several years ago, which prompted to-
day’s visit.
ADDITIONAL HISTORY
His symptoms typically happen shortly after swallowing
solid food, particularly when he is eating fast and takes a
Test Your Knowledge
1. You see a 22-year-old man with recent onset of solid food
dysphagia. His symptoms have gradually worsened, and he
has experienced several bouts of food impaction. He has a
history of asthma and allergic rhinitis and believes that he has
multiple food allergies as well. ness with some pain.
  What is the most likely cause of his dysphagia?
A. Achalasia
B. Eosinophilic esophagitis
C. Schatzki ring
D. Esophageal spasm
• If a food gets stuck and only regurgitation will relieve
the symptom, the patient probably has a mechanical ob-
struction. However, if certain physical maneuvers assist
the passage of food, then the patient likely has a motility
disorder.
PROGNOSIS
The prognosis in patients with dysphagia varies from excel-
lent to poor depending on its cause and severity. In patients
with benign mechanical causes for esophageal dysphagia, the
prognosis is generally excellent. In contrast, the prognosis of
malignant causes for dysphagia is generally poor.
large bite of food such as bread or meat. He does not have
difficulty swallowing liquids. The longest he has had food
stuck has been 30 minutes, during which time he had
severe pain in his chest. He reports rare episodes of heart-
burn and regurgitation, which have been relieved with ant-
acids. He denies smoking or excessive alcohol use.
Question: What is the most likely
diagnosis?
A. Esophageal ring (ie, Schatzki ring)
B. Esophageal cancer
C. Achalasia
D. Esophageal spasm
E. Peptic stricture
2. Your patient, a 42-year-old woman, has a history of progres-
sive dysphagia to solids and liquids for approximately 10
years. Recently, she has begun to lose weight and now sleeps
sitting up to avoid regurgitating liquid. She notes chest full-
  What is the most likely diagnosis?
A. Achalasia
B. Peptic stricture
C. Esophageal cancer
D. Oropharyngeal dysphagia

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Suggested Reading
Richter J. Dysphagia, odynophagia, heartburn and other esophageal
symptoms. In: Sleisenger’s and Fordtram’s Gastrointestinal and
Liver Disease. New York, NY: Elsevier, 2002.