5. Dysphagia / A.S.C. Sekar  

Dysphagia means difficulty in swallowing. Some patients describe food sticking in the throat or retrosternally. 

A careful history is important. Mechanical narrowing is a common cause; an inflammatory stricture must be distinguished from a carcinoma. If the dysphagia is relatively short in duration (e.g., only a few months) and is worsening, this suggests a progressive mechanical narrowing of the lumen such as may occur with an esophageal carcinoma. With benign disease, symptoms are often present for a longer period of time than with carcinoma. A previous history of heartburn or acid regurgitation in a patient with progressive dysphagia might point to an esophageal stricture secondary to gastroesophageal reflux disease. Not all patients with a benign esophageal stricture have a clear history of preceding heartburn or acid regurgitation. This is particularly true in the elderly patient. A history of ingestion of caustic agents such as lye suggests an esophageal stricture secondary to severe chemical esophagitis. 

Infections of the esophagus can also cause difficult swallowing. Infections, usually due to Candida albicans or herpes virus, are often accompanied by significant pain on swallowing, termed odynophagia. Often the odynophagia is so severe that the patient even has difficulty swallowing his or her saliva. Although herpes esophagitis can occur in relatively healthy patients, Candida esophagitis is associated with diabetes, an underlying malignancy or immunosuppression. 

The patient may point to the site of obstruction, but this is not always reliable. A stricture of the lower esophagus may be experienced at the xiphoid area or as high as the throat. Upper esophageal obstruction is experienced high in the throat region, not low in the chest.

Dysphagia can also occur with motor disorders of the esophagus. These conditions include esophageal spasm and achalasia. With motor disorders of the esophagus, the dysphagia may be for both solids and liquids. The dysphagia is intermittent and may have a long history. Sometimes with esophageal spasm the dysphagia may be accompanied by pain (odynophagia), especially with extremely cold or hot liquids. These patients are usually able to wash down impacted particles of food, whereas patients with a mechanical cause (such as a stricture) may need to regurgitate impacted particles of food to obtain relief. 

A common cause of intermittent dysphagia is a mucosal ring at the gastroesophageal junction (lower esophageal or Schatzki’s ring). On occasion when a relatively large bolus of food is swallowed the ring can cause mechanical obstruction, producing a dramatic onset of acute dysphagia (sometimes associated with pain). Often such patients will have to leave the table and regurgitate. Patients with a Schatzki’s ring usually have symptoms for many years before they seek medical attention. 

A rare cause of upper esophageal dysphagia is the Paterson-Kelly syndrome or Plummer-Vinson syndrome. Here, a chronic iron deficiency anemia is associated with narrowing of the upper esophagus due to a web. 

Cricopharyngeal dysphagia may be due to a cricopharyngeal or Zenker’s diverticulum, which develops from an abnormality of the cricopharyngeal sphincter. Patients with a diverticulum often complain of regurgitating food that they swallowed a day or so earlier. 

There are non-esophageal causes of dysphagia. Underlying neuromuscular disease may cause cricopharyngeal dysphagia, where patients have difficulty initiating a swallow. A large goiter or mediastinal tumor can cause extrinsic compression of the upper esophagus. 

A barium swallow is the most important initial investigation in the diagnosis of dysphagia. It might reveal a Zenker’s diverticulum, an esophageal stricture (benign or malignant) or a Schatzki’s ring. If inflammation of the esophagus is suspected, endoscopy with biopsies is indicated. If a stricture is identified on a barium swallow, endoscopy with biopsies is necessary to determine whether this stricture is benign or malignant. Also, benign strictures can be dilated following the endoscopic diagnosis. A barium swallow may help diagnose motility disturbances such as esophageal spasm and achalasia. Esophageal manometry is often required to confirm such motility disturbances. 

Once a cause of dysphagia has been established, management will depend on the cause. For example, reflux esophagitis will be managed with the usual antireflux measures, with or without prokinetic drugs such as domperidone, H₂-receptor antagonists such as ranitidine or a proton pump antagonist such as omeprazole. Esophageal strictures can be dilated following endoscopy. Esophageal carcinoma requires either surgery, radiation or palliative insertion of prosthesis. Esophageal motility disturbances can sometimes be managed medically with nitroglycerin or calcium channel blocking agents. Achalasia and esophageal spasm sometimes require surgical myotomy or pneumatic dilation.