Dysphagia–diagnosing and evaluating

Question 1

What are the 2 phases of dysphagia

Answer 1

Oral pharyngeal phase and the esophageal phase

Question 2

Describe the transit of the bolus in the oropharyngeal phase?

Answer 2

The bolus is transferred to the upper esophagus with the soft palate protecting the nasal passageway and the epiglottis protects the airway.

Question 3

Described the transit of the bolus in the esophageal phase?

Answer 3

The bolus is transferred through the esophagus to the stomach via esophageal peristalsis.

Question 4

What does dysphagia mean? What does odynophagia mean?

Answer 4

1. Difficulty swallowing
2. Pain with swallowing

Question 5

What are the 2 main components of the presentation signs and symptoms of dysphagia that can help narrow down the differential?

Answer 5

1. Nature of onset: sudden CVA or foreign body ingestion vs. subacute infectious or autoinflammatory diseases onset
2. Speed of progression: Non-progressive developmental abnormality vs. a progressive compressive mass affect

Question 6

How can other components of the history including review of systems, past medical history of diagnoses and medications help in diagnosing dysphagia?

Answer 6

With review of systems or may be fever, pain, changes in mental status, muscular weakness numbness outside of the GI tract, rashes. With medical diagnosis there may be Crohn’s disease etc. and with medications there may be yeast and immunosuppression or medication induced esophagitis

Question 7

What underlying etiology of dysphagia to both liquids and solids may be occurring

Answer 7

Dysmotility, which typically occurs in the esophageal phase

Question 8

What underlying etiology of dysphagia occurs with solids alone?

Answer 8

Suggestive of a structural abnormality or mucosal disease and can occur in both the oropharyngeal or esophageal phase issue.

Question 9

What symptoms are more common or consistent with disorders of the oropharynx when evaluating for dysphagia?

Answer 9

1. Delayed swallow initiation
2. Postnasal regurgitation or cough with swallowing
3. Drooling
4. Throat clearing

Question 10

What symptoms are more common with the esophageal dysphagia?

Answer 10

Retrosternal chest pain and a sticking sensation during and after swallowing.

Question 11

What are the differential considerations for oropharyngeal etiologies of dysphagia?

Answer 11

1. Structural causes
2. Infectious/inflammatory mucosal disease and
3. Motility impairment
   Structural causes are ruled out first prior to looking to the other 2

Question 12

What are common structural causes for oropharyngeal etiologies?

Answer 12

1. Cleft lip or palate
2. Goiter
3. Lymphadenopathy i.e. infectious, inflammatory or malignancy.

Question 13

What are the causes for infectious/inflammatory conditions causing dysphagia?

Answer 13

Retropharyngeal/peritonsillar abscess and
Coxsackie, CMV/HSV, epiglottitis

Question 14

What are common neuromuscular disorders as the etiology for oropharyngeal dysphagia?

Answer 14

1. Guillain-Barré, multiple sclerosis, myasthenia gravis, juvenile dermatomyositis
2. CNS tumor or cerebrovascular accident
3. Botulism or tetanus
4. Globus sensation

Question 15

What are the 3 major categories for differential diagnosis and the etiologies for esophageal dysphagia?

Answer 15

1. Structural causes
2. infectious/inflammatory conditions
3. Motility disorders

Question 16

What are some structural causes for esophageal etiologies of dysphagia?

Answer 16

1. Esophageal web, stricture, diverticulum, fistula, swallowed foreign body
2. Mediastinal mass, vascular ring

Question 17

What are some of the infectious/inflammatory conditions as etiologies of esophageal dysphagia?

Answer 17

1. Pill esophagitis, caustic ingestion
2. Candida, eosinophilic esophagitis, HIV
3. GERD

Question 18

What are some of the common motility disorders as etiologies for esophageal dysphagia?

Answer 18

1. Achalasia
2. Scleroderma
3. Diffuse esophageal spasm

Question 19

How is dysphagia best diagnosed?

Answer 19

Most commonly it is diagnosed by clinical suspicion via the history and physical exam.

Question 20

When warranted what further investigation into the differential of dysphagia may be needed?

Answer 20

Serum studies, radiographs, CT, MRI and or PET scans

Question 21

Described fiberoptic endoscopic evaluation.

Answer 21

Fiberoptic scope is used to examine the structure of the oropharynx and the appearance of the tissue, looking for coordination of the rise of the soft palate, protection of the larynx by the epiglottis and movement of the vocal cords

Question 22

How can videofluoroscopic barium swallow studies help with dysphagia diagnosis?

Answer 22

The bolus is followed through oropharyngeal and esophageal phases which may reveal discoordinated aspiration in the oropharyngeal phase or structural impediments such as a foreign body esophageal web, abnormal dilation or fistulizing track

Question 23

How does an upper endoscopy help with the diagnosis of dysphagia and who performs it?

Answer 23

A gastroenterologist uses an endoscope and is able to inspect and biopsied the mucosa of the esophagus, stomach and duodenum. This helps to uncover infectious or inflammatory etiologies in the esophageal dysphagia

Question 24

Describe how manometry of the esophagus or esophageal phase may help.

Answer 24

The manometry catheter is placed in esophagus when the patient is awake and performed a series of swallowing looking for neuro muscular integrity of the esophagus?