Clinical Pearl Series Important Differentiations of Dysphagia

--From [Yale-G First Aid: Crush USMLE Step 2CK and Step 3] By Dr. Yale Gong, USMLE-Certified, Sr. Advisor of www.medicine.net

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Dysphagia refers to difficult swallowing, mostly present in mechanical/obstructive esophageal disorders. Odynophagia refers to painful swallowing, usually associated with esophagitis. The upper esophageal sphincter (UES) and lower esophageal sphincter (LES) have the functions of preventing regurgitation of food upon swallowing. Any disruption in peristalsis, LES, UES, or esophageal anatomy can cause dysphagia or odynophagia. In-time differential diagnosis and management are crucial.

Oropharyngeal dysphagia

Causes: Thyroid disease, Zenker diverticulum (bad breath + neck mass), tumor (progressive), neurologic disease (cranial nerve or bulbar lesion), muscular disease, sphincter dysfunction, and post-surgery/radiation dysphagia.

Diagnosis of choic: Cine-esophagram (videofluoroscopic swallowing exam) + esophageal manometry (motility study). Treat underlying cause.

Esophageal dysphagia

Types by causes: (1) Mechanical obstruction: Mostly partial obstruction and for solid foods, includes Schatzki ring (lower esophageal webs with periodic dysphagia), peptic stricture (progress + chronic heart-burn), cancer (progress + smoking + drinking).

Diagnosis of choice: Barium (Ba) X-ray followed by endoscopy with biopsy.  (2) Motility disorder: Mostly near-full obstruction for solid and liquid foods—achalasia (progressive LES pressure increase), diffuse esophageal spasm (intermittent), scleroderma (chronic heart-burn + Raynaud or CREST syndrome). Diagnosis of choice: Manometry. Treat underlying cause.

Odynophagia

Causes: Neuromuscular disease, candida infection (HIV history + diffuse ulcers), CMV (large shallow ulcers), HSV (small deep ulcers), chemicals (lye or pill ingestion + atypical ulcer).

Diagnosis of choice: Ba X-Ray, Cine-esophagram, or endoscopy. Treat underlying cause.

Diagnostic treatment dysphagia with nitrates and Ca-blockers  

Treatment can lower the pressure in the LES and improve achalasia and diffuse esophageal spasm, but worsen gastroesophageal reflux disease (GERD).