Dysphagia

Dysphagia refers to subjective awareness of difficulty or obstruction during swallowing. It is a relatively common and increasingly prevalent clinical problem. 

Fluoroscopy is the mainstay of imaging assessment but manometry can help evaluate the esophageal motor pattern and lower esophageal sphincter function 1

Dysphagia is common in older age groups. Women are more prone to have dysphagia than men (80% versus 20%) 2.

Dysphagia may be classified depending on the location of this sensation as oropharyngeal or substernal.

Dysphagia can be caused by functional or structural abnormalities of the oral cavity, pharynx, oesophagus, and/or gastric cardia.

Oropharyngeal dysphagia

Oropharyngeal dysphagia occurs when a patient symptomatically localizes a sensation of blockage in the throat.

Functional causes
  • laryngeal penetration (when contrast seen entering the larynx at fluoroscopy) or aspiration (when contrast extends inferiorly through the true vocal), which are common with patients who have a history of neurologic disorders including stroke
  • cricopharyngeal muscle spasm
Structural causes
Substernal dysphagia

Substernal dysphagia occurs when a patient symptomatically localizes a sensation of discomfort or blockage between the thoracic inlet and the xiphoid process.

Functional causes
  • diffuse oesophageal spasm (DES): characterized by multiple spontaneous and uncoordinated esophageal contractions which have the classic "corkscrew" appearance at oesophagogram 
  • achalasia: characterized by esophageal dilatation with distal tapered beaklike narrowing at the gastro-oesophageal junction
  • scleroderma: characterized by esophageal dilatation with a patulous gastroesophageal junction 
Structural causes 
Fluoroscopy
  • modified barium swallow: used for the evaluation of swallowing mechanisms specifically for aspiration or penetration, this exam is usually performed in conjunction with a speech therapist to assess swallowing function and response to therapeutic strategies 4
  • barium swallow / oesophagography: provides anatomic and functional information about the pharynx, oesophagus, gastro-oesophageal junction, and gastric cardia, including evaluation of esophageal motility and assessment for gastroesophageal reflux
  • barium tablet: may be used to detect subtle areas of esophageal narrowing 5
    • the tablet (of known 12.5mm diameter) should be swallowed with a small amount of water and passage is observed at fluoroscopy; f the tablet becomes lodged in a particular location the patient should swallow a small amount of additional water and if the tablet remains lodged, a more detailed assessment should be performed
CT

Cross-sectional imaging may be used especially if there is a mass effect on the oesophagus seen at oesophagography or for evaluation of oesophageal tumors.

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rID: 8055
Section: Gamuts
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Cases and figures

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    Case 1: cricopharyngeal muscle spasm
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    Case 2: oesophageal web
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    Case 3: Zenker diverticulum
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    Case 4: secondary to cervical spine disease
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    Case 5: corkscrew appearance in DES
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    Case 6: beaklike narrowing in achalasia
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    Case 7: scleroderma
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    Case 8: peptic stricture
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    Case 9: Schatzki ring
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    Case 10: long segment corrosive esophagitis
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    Case 11: dysphagia lusuria
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    Case 12: oesophageal cancer
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    Case 13: swallowed pen with esophageal perforation
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    Case 14: dysphagia megalatriensis
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