Esophageal dysphagia

Thanks to Tyler Mains and Matt Hickey for presenting a case of an elderly man with unintentional weight loss and esophageal dysphagia.
When evaluating dysphagia, the two initial branch points are…
is this
  • odynophagia
  • globus sensation
  • dysphagia
AND
is this
  • oropharyngeal dysphagia or
  • esophageal dysphagia
esophageal dysphagia
Characterized by food sticking in the throat, regurgitation and/or chest pain. Solids > liquids makes you think of esophageal obstruction. Esophageal dysphagia for liquids makes you think about
Ddx – can be organized anatomically
  • intraluminal
    • food impaction
  • intrinsic (inside the esophagus)
    • stricture/web/ring
      • remember plummer vinson syndrome from step 1? Esophageal webs d/t longstanding iron deficiency anemia.
    • esophagitis
      • infectious
      • eosinophilic
      • lymphocytic
    • malignancy
    • radiation or caustic injury
    • esophageal diverticulum
  • extrinsic (outside the esophagus)
    • “dysphagia lusoria” is a very uncommon condition where vascular abnormalities compress the esophagus they include…
      • large thoracic aortic aneurysms
      • vascular malformations
      • massive left atrium
      • pericardial effusion (seen recently at ZSFG!)
    • malignancies
  • motility disorders
    • long list, the topic of their own pearls
  • functional
    • when you can’t find another cause
Workup
Once you have confirmed esophageal dysphagia, the next major branchpoint is what kind of diagnostic imaging to obtain. Options include
  • EGD
  • barium swallow
  • motility testing.
An EGD is almost always the test of choice given that it can be diagnostic, therapeutic, and gives the opportunity for biopsy. A couple caveats
1) Times to start with a barium swallow.
  • risk of esophageal perforation due to structural abnormalities like…
    • hx radiation or cancer
    • proximal esophageal cancer or zenker’s diverticulum
2) Conditions in which the EGD is negative
  • extrinsic compression
  • motility disorders
For the more visual people, here is the Rome foundation algorithm for workup of esophageal dysphagia
dysphagia-diagnostic-algorithm
Kahrilas PJ1, Smout AJ. Esophageal disorders. Am J Gastroenterol. 2010 Apr;105(4):747-56.
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