Dysphagia

Dysphagia as defined subjectively is the sensation of a delay in transit of a liquid or solid bolus during the oropharyngeal or esophageal stages of swallowing (oropharyngeal and esophageal dysphagia, respectively).

Complaints of dysphagia (difficult swallowing) are common, especially in aging persons. Approximately 7 to 10 percent of adults older than 50 years have dysphagia, although this number may be artificially low because many patients with this problem may never seek medical care. Up to 25 percent of hospitalized patients and 30 to 40 percent of patients in nursing homes experience swallowing problems.

Physiology of Swallowing

  1. Oropharyngeal stage -
  2. Esophageal stage - controlled by the medulla but initiated by the cerebral cortex. Involuntary contractions of the skeletal muscles of the upper esophagus force the bolus through the mid and distal esophagus. The lower esophageal sphincter relaxes at the initiation of the swallow, and this relaxation persists until the food bolus is propelled into the stomach. It may take 8-20 seconds for the contractions to drive the bolus into the stomach

Diagnostic Approach to Dysphagia

Initial Classification

  1. Oropharyngeal vs esophageal.
    1. In oropharyngeal dysphagia, symptoms arise from the dysfunctional transfer of a food bolus in the pharynx past the upper esophageal sphincter into the esophagus.
      1. Stroke
    2. Esophageal dysphagia is caused by disordered peristaltic motility or conditions that obstruct the flow of a food bolus through the esophagus into the stomach.
      1. Motility: achalasia, scleroderma
      2. Anatomic: cancer, stricture, Schatzki's ring
  2. Motility vs structural/anatomic.
    1. Motility disorder:
      1. Tends to affect both solids and liquids
    2. Mechanical obstruction:
      1. Solid foods only

References

  1. Approach to the evaluation of dysphagia in adults - UpToDate
  2. Evaluating Dysphagia | AAFP
  3. Jalil et al. Approach to the Patient with Dysphagia. Am J Med 2015
  4. CAG 2018 - CPG for the Assessment of Uninvestigated Esophageal Dysphagia
  5. 2021 IM Review Slides