Dysphagia

Dysphagia is difficulty moving food or liquid from the mouth to the stomach. It signals structural, motility or neuromuscular disease. New progressive dysphagia in an adult is oesophageal or gastro-oesophageal junction cancer until proved otherwise.

Physiology. The oral phase prepares and propels the bolus voluntarily. The pharyngeal phase is involuntary and lasts about one second: the soft palate rises, the larynx elevates, the epiglottis inverts and the upper oesophageal sphincter relaxes. The oesophageal phase is vagally driven peristalsis with relaxation of the lower oesophageal sphincter. Failure at any step causes dysphagia.

Classification by site.

• Oropharyngeal (transfer) dysphagia: difficulty initiating a swallow, coughing or choking during the swallow, nasal regurgitation, wet voice. Neuromuscular disease dominates.
• Oesophageal dysphagia: food sticks seconds after the swallow. The perceived level is unreliable, because a distal lesion can be felt in the neck.

Classification by mechanism.

• Solids only suggests mechanical narrowing. Symptoms from rings and strictures usually appear when the lumen is under about 13 mm.
• Solids and liquids from the outset suggests a motility disorder.
• Progression from solids to liquids suggests a worsening stricture or tumour.

Temporal pattern. Hours: food bolus impaction, foreign body, caustic ingestion. Weeks to months and progressive: malignancy. Intermittent over years: rings, webs, eosinophilic oesophagitis, spasm.

Consequences. Aspiration pneumonia, malnutrition, dehydration, food impaction and weight loss. Dysphagia is common after stroke and in neurodegenerative disease and older adults. Squamous cell carcinoma predominates in East and Southern Africa and is a leading cause of progressive dysphagia in adults there.

History.

• Tempo, level (neck or retrosternal), solids versus liquids, difficulty starting the swallow.
• Coughing, choking, nasal regurgitation, hoarseness, odynophagia.
• Regurgitation of undigested food hours later or at night (achalasia, pouch).
• Long standing heartburn (peptic stricture, Barrett oesophagus with adenocarcinoma).
• Atopy and recurrent food impaction in a young man (eosinophilic oesophagitis).
• Weight loss, haematemesis, melaena, symptoms of anaemia.
• Drugs: bisphosphonates, doxycycline, potassium chloride, NSAIDs, iron.
• Immune status: HIV, steroids including inhaled steroids (candidiasis, herpes, cytomegalovirus).
• Radiotherapy, caustic ingestion, fundoplication or bariatric surgery.
• Neurological symptoms: diplopia, fatigable weakness, tremor, limb weakness.
• Raynaud phenomenon and skin tightening (systemic sclerosis), iron deficiency in a woman (web), Chagas exposure, smoking and alcohol.

Examination.

• Nutrition, hydration, pallor, supraclavicular nodes (left side, Virchow node), neck mass or goitre.
• Mouth and oropharynx: thrush, mass, saliva pooling, tongue fasciculation, dentition.
• Voice quality, palatal movement, cranial nerves, ptosis with fatigability, limb tone, power and reflexes, tremor and rigidity.
• Sclerodactyly, telangiectasia, calcinosis. Chest crackles. Epigastric mass, hepatomegaly.

Bedside swallow test. Observe 90 mL of water drunk without interruption. Coughing or a wet voice within one minute indicates aspiration risk. The test misses silent aspiration.

Red flags.

• Progressive solid dysphagia, unintentional weight loss, new dysphagia at any age.
• Haematemesis, melaena, iron deficiency anaemia, persistent vomiting.
• Drooling, inability to swallow saliva, stridor.
• Chest pain with fever after vomiting (rupture).
• Caustic ingestion. Hoarseness or neck mass. Recurrent aspiration pneumonia.
• Acute neurological signs, tongue fasciculations with bulbar weakness.

Oropharyngeal.

• Neurological: stroke and brainstem lesions, Parkinson disease, motor neurone disease, myasthenia gravis, multiple sclerosis, Guillain-Barre syndrome, botulism, dementia.
• Muscular: polymyositis, dermatomyositis, inclusion body myositis, oculopharyngeal muscular dystrophy, myotonic dystrophy, thyroid myopathy.
• Structural: Zenker diverticulum, cricopharyngeal bar, oropharyngeal and hypopharyngeal cancer, postradiation fibrosis, cervical osteophytes, retropharyngeal or peritonsillar abscess, goitre, postsurgical change.
• Other: xerostomia (Sjogren syndrome, radiotherapy, anticholinergics), oropharyngeal candidiasis.

Oesophageal, mechanical.

• Oesophageal carcinoma (squamous or adenocarcinoma), gastric cardia cancer.
• Peptic stricture, Schatzki ring, oesophageal web (Plummer-Vinson syndrome).
• Eosinophilic oesophagitis, pill oesophagitis.
• Infective oesophagitis: Candida, herpes simplex, cytomegalovirus.
• Caustic or radiation stricture.
• Extrinsic compression: mediastinal nodes (tuberculosis, lymphoma), lung cancer, left atrial enlargement, aortic aneurysm, aberrant right subclavian artery (dysphagia lusoria), goitre.
• Hiatus hernia, food bolus or foreign body, postfundoplication or banding.

Oesophageal, motility. Achalasia (primary, or secondary to cardia cancer or Chagas disease), diffuse oesophageal spasm, hypercontractile (jackhammer) oesophagus, ineffective motility, systemic sclerosis.

1. Decide oropharyngeal versus oesophageal from the history. Assess airway, aspiration risk and hydration first.
2. Baseline tests: full blood count, ferritin, urea and electrolytes, albumin, glucose, thyroid function, creatine kinase when myopathy is suspected, HIV test with consent, chest radiograph (aspiration, mediastinal mass, dilated oesophagus).
3. Oesophageal or any new progressive dysphagia: upper endoscopy with biopsy. It allows biopsy and treatment. Take at least six biopsies from two levels when eosinophilic oesophagitis is possible, even if the mucosa looks normal. Diagnosis needs symptoms plus 15 or more eosinophils in a high power field and exclusion of other causes. Biopsy any stricture or mass and brush for Candida.
4. Barium swallow first for suspected Zenker diverticulum (blind endoscopy risks perforation) and complex strictures. Add a timed barium column (height at 1, 2 and 5 minutes) when achalasia is suspected; a bird beak narrowing is typical. A solid bolus (tablet or marshmallow) improves detection of rings.
5. Oropharyngeal dysphagia: videofluoroscopy (modified barium swallow) shows transfer, residue and aspiration. Fibreoptic endoscopic evaluation of swallowing is a bedside alternative.
6. High resolution manometry when endoscopy and barium are unhelpful or achalasia is suspected. Achalasia shows absent peristalsis with an elevated integrated relaxation pressure (threshold depends on the device, about 15 mmHg). Subtype I, II or III directs treatment.
7. Staging for cancer: CT chest and abdomen, endoscopic ultrasound, PET CT where available.
8. Neuromuscular work up: MRI brain, acetylcholine receptor and MuSK antibodies, electromyography, muscle biopsy as directed by neurology.

Limits. A normal endoscopy does not exclude eosinophilic oesophagitis or a motility disorder. Barium misses mild disease. Bedside tests miss about half of silent aspirators.

Immediate. Aspiration precautions, upright positioning, nil by mouth if swallowing is unsafe, intravenous fluids.

Food bolus impaction.

• If the patient cannot swallow saliva, arrange endoscopic removal urgently (within 6 hours, and always within 24 hours).
• Glucagon is not advised. Meat tenderiser is contraindicated because of perforation.
• Sharp objects and button batteries need emergency removal.
• Suspected perforation: nil by mouth, broad spectrum intravenous antibiotics, contrast CT, surgical review.

Caustic ingestion. No induced vomiting. Endoscopy within 12 to 24 hours with specialist care.

Cause directed treatment.

• Cancer: urgent surgical and oncology referral, nutritional support, stent or feeding tube as directed.
• Peptic stricture: omeprazole 40 mg orally once daily for 8 weeks then lowest effective dose long term (maximum usual 40 mg twice daily), with endoscopic balloon or bougie dilatation.
• Eosinophilic oesophagitis: omeprazole 20 mg orally twice daily for 8 weeks, then repeat biopsies. If not controlled, swallowed fluticasone propionate 880 micrograms twice daily (without a spacer) for 8 weeks, or budesonide orodispersible 1 mg twice daily for 6 to 12 weeks. Dupilumab 300 mg subcutaneously once weekly is a specialist option. Dietary elimination is an alternative.
• Achalasia: pneumatic dilatation, laparoscopic Heller myotomy with partial fundoplication, or peroral endoscopic myotomy; botulinum toxin 100 units into the sphincter for patients unfit for these. Nifedipine 10 to 20 mg sublingually before meals is a short term bridge.
• Candida oesophagitis: fluconazole 200 to 400 mg orally once daily for 14 to 21 days (maximum 400 mg daily; halve the dose when eGFR is under 50 mL/min); start antiretroviral therapy in untreated HIV.
• Herpes oesophagitis: aciclovir 400 mg orally five times daily for 7 to 14 days (5 mg/kg intravenously every 8 hours if unable to swallow). Cytomegalovirus: specialist directed ganciclovir.
• Pill oesophagitis: stop the drug, take tablets upright with 200 mL of water, add a proton pump inhibitor.
• Oropharyngeal dysphagia: speech and language therapy, texture modified diet, thickened fluids, chin tuck technique, treat the cause. Use nasogastric feeding when swallowing stays unsafe and consider gastrostomy when recovery is not expected within about 4 weeks. Myasthenia gravis, motor neurone disease and myositis need specialist treatment.
• Zenker diverticulum: endoscopic or open cricopharyngeal myotomy with diverticulotomy.

Monitoring. Weight and nutrition (screening tool and dietitian), repeat endoscopy and biopsies for eosinophilic oesophagitis at 8 to 12 weeks, recurrent dilatation needs, aspiration pneumonia.

Referral and escalation. Urgent endoscopy and surgical or oncology referral for suspected cancer. Same day referral for impaction, caustic ingestion or inability to swallow saliva. Neurology for suspected neuromuscular disease and ENT for pharyngeal lesions.

Admission. Inability to swallow saliva, aspiration pneumonia, dehydration, impaction, suspected perforation, new neurological deficit.

Special groups. Children: foreign body, eosinophilic oesophagitis, congenital stricture and vascular rings. Pregnancy: endoscopy is preferred to CT; omeprazole is acceptable. HIV: candidiasis, herpes, cytomegalovirus, tuberculosis and lymphoma are likelier.