Dysphagia Overview

• Disruptions in the swallowing mechanism, preventing bolus passage from mouth to stomach, defines dysphagia.
• Differentiation between oropharyngeal and esophageal causes is crucial for diagnosis and treatment.

Normal Swallowing Phases:

• Oral: Bolus formation and transfer to the throat.
• Pharyngeal: Bolus positioning, soft palate elevation, epiglottis protection.
• Esophageal: Bolus entry via sphincter relaxation, peristalsis (primary and secondary), LES relaxation for stomach entry.

Oropharyngeal Dysphagia

• Occurs when the food bolus cannot be transferred from the mouth into the upper esophagus by swallowing.
• Symptoms include choking, coughing, and nasal regurgitation.
• Patients face a risk of aspiration pneumonia.
• Stroke is a common cause, and Parkinson disease is a suspected underlying neurologic disorder.
• Zenker diverticulum is suspected if undigested food is regurgitated hours after meals or if a gurgling noise is heard in the throat.
• Initial study: modified barium swallow with video fluoroscopy.
• Management involves dietary changes and swallowing exercises with a speech pathologist.

Esophageal Dysphagia

• Patients can initiate swallowing but feel chest discomfort.
• Described sensations include food "hanging up," feeling lodged, or a slow bolus.
• Sometimes manifests as vomiting of undigested food.
• Causes: mechanical obstruction or motility disorder.
• Solids-only dysphagia suggests mechanical obstruction.
• Liquids-only or liquids-and-solids dysphagia indicates a motility disorder.
• An urgent workup is needed for complete obstruction, hematemesis, odynophagia, older-age onset, or dysphagia with weight loss.
• Food impaction requires emergency endoscopy.
• Mechanical obstructions include masses, strictures, esophageal rings (e.g., Schatzki ring), webs, or complex hiatal hernias.
• Progressive dysphagia (solids to both solids and liquids) can indicate malignancy or high-grade benign strictures.
• Achalasia presents with dysphagia for solids and liquids, plus nonacidic regurgitation.
• Chest pain upon ingestion of very hot or very cold liquids may indicate esophageal spasm.
• Upper endoscopy allows for diagnosis and therapeutic dilation and is the usual initial test of choice.
• Barium esophagography may provide more information in specific situations, such as suspicion of motility disorders or proximal lesions (e.g., Zenker diverticulum).

Odynophagia

• Pain while swallowing, indicating mucosal inflammation and ulceration.
• Commonly from pill-induced damage, infection, or caustic ingestion.
• Less commonly due to GERD or esophageal cancer.
• Upper endoscopy with biopsy is the best diagnostic test.

Globus Sensation

• Feeling a lump in the throat, usually not meal-related.
• Causes include GERD, motility disorders, stress, and psychiatric conditions
• Should not be diagnosed if dysphagia or odynophagia is present.
• Assessment includes evaluation for thyroid goiter and pharyngeal lesions.
• Treatment: acid suppression or cognitive behavioral therapy, after ruling out structural causes.

Reflux and Chest Pain

• Esophageal chest pain can mimic cardiac pain and a cardiac cause must first be ruled out.
• The most common cause of noncardiac chest pain is GERD.
• Esophageal motility disorders are another possible cause.
• Heartburn with Raynaud phenomenon history could signify systemic sclerosis.
• Acid-reducing agents can be diagnostic and therapeutic.
• Non-responders require upper endoscopy and possibly pH testing with/without manometry.
• Effort rupture of the esophagus (Boerhaave syndrome) presents with severe pain after vomiting.

Gastroesophageal Reflux Disease

• GERD is a condition where stomach contents reflux into the esophagus.
• Has a prevalence of 10% to 20% in the Western world.
• Obesity is strongly related to GERD.
• Common symptoms are heartburn, regurgitation, and chest pain, for which a cardiac cause must be excluded.
• Factors that trigger reflux include specific foods and lifestyle habits.
• Protective mechanisms: salivary bicarbonate, peristalsis, competent LES, and gastric emptying.
• Long-standing GERD can lead to reflux esophagitis, stricture, Barrett esophagus, and esophageal adenocarcinoma.
• Extraesophageal conditions include chronic cough, hoarseness, wheezing, and dental erosions.
• Pregnant individuals may experience GERD during any trimester, symptoms may worsen as the pregnancy progresses, and typically resolve after delivery.

GERD Diagnosis

• Clinical history, response to medical therapy, endoscopy, and ambulatory pH monitoring.
• No single gold-standard test exists.
• Alarm features: dysphagia, weight loss, hematemesis, or melena.
• In the absence of alarm features, an 8-week PPI trial can be done.
• Upper endoscopy is warranted for alarm features or treatment failure.and it can rule out structural abnormalities.

GERD Testing

• Ambulatory pH monitoring quantifies esophageal acid exposure.
• Impedance-pH testing differentiates between acid and nonacid reflux.
• Testing uses a transnasal catheter (24-hour) or wireless capsule endoscopy (48/96-hour).
• Esophageal manometry rules out motility disorders.

GERD Treatment

• Patients with recent weight gain or who are overweight should have a weight-loss plan.

GERD Lifestyle Changes

• Weight loss plan for those overweight.
• Avoid eating 3 hours before sleep, elevate the head of the bed for nocturnal GERD.
• Avoid large meals and rich/fatty foods.
• Eliminate specific trigger foods, not all common ones.
• Cessation of alcohol and tobacco use.

GERD Medical Therapy

• Antacids, H2 blockers, and PPIs.
• PPI once daily for 8 weeks is the preferred therapy.
• Take PPIs 30-60 minutes before the first meal.
• For partial response, increase the dosage to twice daily.
• Use the lowest effective dose of PPI.
• Stopping or reducing long-term PPI therapy should be attempted once a year for uncomplicated GERD.
• Switching PPIs may be needed for adverse reactions or unresponsive symptoms.
• PPIs are safe in pregnancy.
• Vonoprazan is reserved for patients who do not respond to PPIs because of limited data on long-term safety,.
• Prokinetic agents (e.g., metoclopramide) should only be used if gastroparesis is present.

GERD Surgery

• Considered for PPI failure, desire to stop medication, or intolerable side effects.
• Objective testing should be performed before surgery.
• Surgical treatments include laparoscopic fundoplication or bariatric surgery.
• Magnetic sphincter augmentation may also be performed (a magnetic ring is placed around the LES without surgical alteration of the stomach).
• Most effective in patients with severe reflux esophagitis, large hiatal hernias, or persistent symptoms.
• Complications: dysphagia, diarrhea, and inability to belch.

GERD Endoscopic Therapy

• Transoral incisionless fundoplication is an option for those not wanting surgery, without severe esophagitis or large hiatal hernias.
• Additional therapies have unproven long-term benefits.

GERD Extraesophageal Manifestations

• Asthma, chronic cough, and laryngitis are linked to GERD.
• Other non-GERD causes should be eliminated.
• Laryngoscopy shouldn't be used to diagnose GERD laryngitis.
• A PPI trial is recommended in patients who have concomitant typical GERD symptoms.
• For patients with atypical symptoms only, ambulatory esophageal pH monitoring should be obtained before a PPI trial.
• Surgery is less effective in this group and should be considered only in patients whose symptoms respond to PPI therapy.

GERD Refractory Cases

• Optimize PPI therapy (timing, dosage, or switching PPIs).
• Consider alternative causes.
• Endoscopy rules out eosinophilic or erosive esophagitis.
• Esophageal impedance-pH testing confirms acid suppression adequacy.
• Impedance-pH testing conducted off acid-suppression therapy may help confirm the diagnosis of acid reflux.
• Consider therapy for functional heartburn with antidepressants if other tests are normal.

Eosinophilic Esophagitis

• Commonly associated with dysphagia and food bolus obstruction
• Diagnosed between the second and fifth decades of life, and more common in men
• Patients often have other atopic conditions, such as asthma, rhinitis, dermatitis, and seasonal or food allergies.
• Diagnostic criteria: esophageal symptoms, eosinophil count ≥15/hpf, exclusion of other causes.
• Endoscopic findings include rings, furrows, luminal narrowing, and strictures.
• Therapy is based on excluding other causes of eosinophilia is a PPI, topical steroids (fluticasone or budesonide), or dupilumab.
• Empirical diet may be effective to prevent EoE.
• Endoscopic dilation should be considered in patients with continued dysphagia caused by esophageal stricture not responding to medical therapy.

Infectious Esophagitis

• Caused by fungal, viral, bacterial, or parasitic pathogens.
• Most common in immunocompromised patients.
• Presents with odynophagia or dysphagia.
• Candida esophagitis causes dysphagia, whereas viral esophagitis produces odynophagia.

Candida Esophagitis

• Can occur in immunocompetent or immunocompromised hosts.
• Diagnosis: compatible symptoms and oral candidiasis.
• Endoscopy with biopsy can be considered for patients who do not respond to empiric therapy or who have atypical symptoms.
• Endoscopy shows small, white, raised plaques.
• Esophageal brushings confirm the diagnosis.
• Treatment: oral fluconazole for Candida albicans.

Viral Esophagitis

• Herpes simplex virus and cytomegalovirus are seen in immunodeficient or immunosuppressed individuals
• Endoscopy with biopsy confirms the diagnosis.
• Treatment: acyclovir for herpes simplex and ganciclovir or valganciclovir for cytomegalovirus.

Pill-Induced Esophagitis

• Results from medications causing esophageal injury.
• Risk factors: decreased salivary output, dysmotility, large pills, increased LES tone, supine ingestion.
• Symptoms: chest pain, dysphagia, and odynophagia hours to days after medication.
• Diagnosed by history alone, but upper endoscopy should be performed for severe symptoms, persistent symptoms, or atypical symptoms.
• Prevention: drink water with medications and remain upright for 30 minutes.

Esophageal Motility Disorders

• Esophagus passes bolus from hypopharynx to the stomach through peristalsis.
• High-resolution esophageal manometry is used to evaluate suspected esophageal motility disorders.
• Upper third is skeletal muscle; lower two thirds is smooth muscle.

Hypertonic Motility Disorders

• Characterized by dysphagia with liquids and solids and regurgitation of undigested food.

Achalasia

• Defined by inadequate LES relaxation and aperistalsis.
• Can be idiopathic or associated with viral, autoimmune, neurodegenerative disorders, and infection (Chagas disease).
• Damage to the ganglion cells results in unopposed cholinergic nerve activation.
• Affects men and women equally, typically between 30 and 60 years.
• Symptoms include dysphagia, nonacidic regurgitation, heartburn, weight loss, and chest pain.
• Upper endoscopy, barium esophagography, and manometry are complementary diagnostic tests.
• Upper endoscopy rules out structural causes.
• Barium esophagography shows esophageal dilation with narrowing at the gastroesophageal junction (bird's beak).
• Esophageal manometry shows incomplete LES relaxation and aperistalsis.

Pseudoachalasia

• Results from malignant tumor infiltration or other secondary causes.
• Associated with sudden weight loss later in life.
• Three clinical features suggest cancer: short duration, weight loss, and age >55 years.
• Evaluation: CT, endoscopy, or endoscopic ultrasonography.

Achalasia Treatment

• Endoscopic or surgical intervention to lower LES pressure.
• Botulinum toxin injection into the LES inhibits acetylcholine release.
• Pneumatic dilation disrupts the circular muscle. Clinical symptom relief ranges from 50% to 90%, and the most common complication is perforation.
• Surgical treatment: laparoscopic myotomy with partial fundoplication.
• POEM entails creation of an esophageal submucosal tunnel extending to the LES and then a myotomy.
• Medical therapy: calcium channel blockers (nifedipine) or long-acting nitrates for poor candidates for endoscopic or surgical therapy.
• Patients with achalasia for >10 years have increased risk for squamous cell carcinoma.

Diffuse Esophageal Spasm and Jackhammer Esophagus

• Present with chest pain or dysphagia.
• Esophagography appearance in diffuse esophageal spasms: "corkscrew" or "rosary bead".
• Jackhammer esophagus: high-vigor peristaltic contractions.
• Symptoms often respond to nitroglycerin.
• Treat GERD symptoms with a PPI.
• Medical therapy: antidepressants or sildenafil for those without GERD.
• Botulinum toxin injection can alleviate dysphagia symptoms.

Hypotonic Motility Disorders

• Marked by lack of contractility and incomplete peristalsis.
• Patients may report GERD symptoms due to decreased LES pressure or dysphagia.
• Causes: smooth-muscle relaxants, anticholinergic agents, estrogen, progesterone, connective tissue disorders, and pregnancy.
• Esophageal manometry shows weak nonperistaltic contractions.
• Treatment: lifestyle changes (eating upright) and acid-reducing agents.
• Prokinetic agents are not recommended.

Barrett Esophagus

• Replacement of squamous epithelium with metaplastic columnar epithelium.
• Consequence of GERD and precursor to esophageal cancer.
• Risk factors: chronic GERD, age >50 years, male sex, tobacco use, and obesity.
• Drinking alcohol is not associated with increased risk for Barrett esophagus, and wine consumption might be protective.
• Annual cancer risks: 0.2-0.5% for no dysplasia, 0.7% for low-grade dysplasia, and 7% for high-grade dysplasia.
• Screening may benefit those with multiple risk factors and chronic GERD.
• Barrett esophagus is diagnosed by endoscopic findings with biopsy, which are then confirmed by pathology showing specialized intestinal metaplasia with acid-mucin–containing goblet cells.
• Swallowable capsule sponge device can be used for screening as nonendoscopic alternative.

This lesson covers the phases of swallowing, definition of dysphagia and its common symptoms. It also includes diagnostic procedures for oropharyngeal and esophageal dysphagia, differentiating between mechanical obstruction and motility disorders. Neurological associations and specific conditions related to dysphagia are discussed.