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4.1 Symptoms
This sensation of food sticking during swallowing is a manifestation of impaired transit of food through the mouth, pharynx or esophagus. It is important to differentiate oropharyngeal ("transfer") dysphagia from esophageal dysphagia. If the patient has problems getting the bolus out of the mouth, then one can be certain of an oropharyngeal cause; if the food sticks retrosternally, an esophageal cause is indicated. Some patients, however, will sense food sticking at the level of the suprasternal notch when the actual obstruction is the distal esophagus. Thus, it can be difficult to determine the site of the problem when patients refer their dysphagia to the suprasternal notch or throat area. With these patients it is important to elicit any ancillary symptoms of oropharyngeal-type dysphagia, such as choking or nasal regurgitation. It may also be helpful to observe the patient swallowing in an attempt to determine the timing of the symptom; with esophageal dysphagia referred to the suprasternal notch, the sensation of dysphagia onsets several seconds after swallowing begins. The history can also be used to help differentiate structural from functional (i.e., motility disorders) causes of dysphagia. Dysphagia that is episodic and occurs with both liquids and solids from the outset suggests a motor disorder, whereas when the dysphagia is initially for solids such as meat and bread, and then progresses with time to semisolids and liquids, one should suspect a structural cause (e.g., stricture). If such a progression is rapid and associated with significant weight loss, a malignant stricture is suspected. Associated symptoms help determine the etiology of dysphagia. For instance, a reflux-induced stricture should be suspected if the dysphagia is associated with heartburn or regurgitation, esophageal cancer if there is associated mid-back pain and weight loss, a motor disorder such as diffuse esophageal spasm if there is angina-like chest pain, and a "scleroderma esophagus" if there is arthralgia, skin changes or Raynaud's phenomenon.
This refers to the sensation of pain on swallowing. Local inflammation or neoplasia in the mouth and pharynx can produce such pain. When the pain is retrosternal, one should suspect nonreflux-induced forms of esophagitis, such as infection, radiation or pill-induced (chemical) injury. Less commonly it occurs with esophageal cancer, a deep esophageal ulcer (e.g., Barrett's ulcer) or esophageal motor disorders.
The sensation here is one of retrosternal burning. Typically it begins in the low retrosternal area and radiates up to the throat. It may be precipitated by bending over or lying down, and usually begins shortly after consuming certain foods or beverages. It is often associated with regurgitation of acidic material into the back of the throat. "Heartburn" with these features indicates gastroesophageal reflux. This very common symptom has been experienced at one time or another by over one-third of the population and therefore does not necessarily indicate serious disease. Many patients will complain of "heartburn," but this should not be taken at face value: this term is used by some patients to describe unrelated symptomatology. It is therefore important to have patients describe exactly what they mean by the term heartburn.
This refers to the spontaneous appearance of food or fluid in the back of the throat or in the mouth. Some patients describe this symptom as "vomiting"; therefore it is important to determine whether there is associated nausea, retching, etc., when patients present with "vomiting." The taste and consistency of the regurgitated material is an important historical detail. Regurgitation of acidic or bile-stained fluid indicates gastroesophageal reflux. Regurgitation of undigested food or stagnant fluid devoid of an acidic taste indicates an esophageal transport problem (e.g., achalasia). (With achlorhydria, gastric contents also lack acid.) In motor disorders and mechanical obstruction of the esophagus, food may become stuck and then rather quickly will be regurgitated if it does not pass through into the stomach. Some patients regurgitate food back into their mouths after a meal only to chew and swallow it all over again. This is called rumination and, although a rarity in humans, it is a normal physiological event in certain animals.
This can also indicate esophageal disease. Chest pain, and in particular mid-dorsal pain, is seen in advanced esophageal cancer. The most common type of nonheartburn esophageal chest pain, however, is a pain that is qualitatively similar to the pain of ischemic heart disease. This pain can be squeezing or crushing and can radiate into the jaw or arms. Unlike ischemic heart pain, angina-like chest pain of esophageal origin is not predictably elicited by exertion and often occurs spontaneously, in relationship to meals or in the middle of the night. It is associated with other esophageal symptoms. Clearly, patients with this type of pain need to have ischemic heart disease excluded. Once this is done, many will be found to have some form of esophageal motor disorder. In addition, this angina-like pain can be precipitated by gastroesophageal reflux.
This sudden appearance of copious amounts of saliva in the mouth must be differentiated from regurgitation of fluid. With waterbrash, acid reflux into the esophagus stimulates hypersalivation via a (cholinergic) neural reflex.
This may be a symptom of certain esophageal diseases. Mucosal laceration in the region of the gastroesophageal junction (Mallory-Weiss tear), as a consequence of retching or vomiting, is a common cause of upper gastrointestinal tract bleeding. Esophageal varices can cause massive hematemesis and melena. Deep esophageal ulcers may also bleed massively, but this is uncommon. Usually the bleeding from ulcerative lesions of the esophagus or esophageal cancer is occult. When the patient does present with hematemesis or melena from esophagitis, the rate of bleeding is usually slow; therefore, significant hemodynamic compromise is uncommon.
These may be a manifestation of esophageal disease or oropharyngeal swallowing disorders. Aspiration at the time of swallowing will cause coughing, choking and eventual hoarseness. In addition, patients with motor disorders or gastroesophageal reflux disease (GERD) may regurgitate esophageal or gastric contents up into the larynx and subsequently aspirate. These patients may present with pneumonia, chronic cough, wheezing, hoarseness or laryngitis. Gastroesophageal reflux may also trigger coughing and wheezing via a vasovagal reflex.
It is uncommon for esophageal disease to be associated with specific physical findings. Signs of weight loss and malnutrition can be found if the esophageal problem is so severe that adequate caloric intake is not maintained. There may be signs of metastatic disease (e.g., hepatomegaly, supraclavicular lymphadenopathy) in esophageal cancer. Patients with GERD rarely have respiratory tract signs such as wheezing, hoarseness or lung consolidation. It is important to look for signs of connective tissue disease (especially scleroderma) in patients with reflux symptoms or dysphagia. The physical examination is more often helpful in patients with oropharyngeal dysphagia. Careful examination of the head and neck for structural and neurologic abnormalities is mandatory. It is also important to look for more generalized neurologic or connective tissue abnormalities. Observing the patient swallow is also useful when oropharyngeal dysphagia is present. |
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