Dysphagia

Dysphagia refers to subjective awareness of difficulty or obstruction during swallowing.

Dysphagia is a relatively common and increasingly prevalent clinical problem.

Epidemiology

Dysphagia is common in older age groups²

Women are more prone to have dysphagia than men (80% versus 20%)²

Pathology

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

Dysphagia can be caused by functional or structuralabnormalities of the oral cavity, pharynx, esophagus, and/or gastric cardia.

Imaging

Fluoroscopic studies

• modified barium swallow , used for the evaluation of swallowing mechanisms specifically for aspiration or penetration, this exam is usually performed in conjunction with a swallowing therapist to assess swallowing function and response to therapeutic strategies ⁴
• barium swallow /esophagography provides anatomic and functional information about the pharynx, esophagus, gastroesophageal junction (GEJ), 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. If the tablet becomes lodged in a particular location the patient should swallow a small amount of additional water. If the tablet remains lodged, a more detailed assessment should be performed

Manometry can help evaluate the esophageal motor pattern and lower esophageal sphincter function.¹

Cross-sectional imaging may be used especially If there's a mass effect on the esophagus seen at esophagography or for evaluation of esophageal tumors.

Classification

Oropharyngeal dysphagia

orophatyngeal dysphagia occurs when a patient symptomatically localizes a sensation of difficulty passing foodblockage in the throat, It can be caused by:

Functional causes

• laryngeal penetration (when contrast seen entering the larynx at fluoroscopy) or liquid from the mouthaspiration(when contrast extends inferiorly through the pharynxtrue vocal), which are common with patients who have a history of neurologic disorders including stroke
• cricopharyngeal muscle spasm

Structural causes:

• oesophageal web,
• oesophageal diverticula, e.g. Zenker, Killian-Jamieson, and epiphrenic diverticula
• tumors,
• extrinsic masses e.g. thyroid disease, or cervical spine disease.

Substernal dysphagia

substernal dysphagia occurs when a patient symptomatically localizes a sensation of discomfort or blockage between the thoracic inlet and into the stomachxiphoid process.

Causes of dysphagia It can be divided broadly into mechanicalcaused by:

Functional causes

• diffuse oesophageal spasm (DES), characterized by multiple spontaneous and neuromuscular (motor).uncoordinated esophageal contractions which have the classic "Corkscrew" appearance at esophagogram 
• achalasia, characterized by esophageal dilatation with distal tapered beaklike narrowing
• scleroderma, characterized by esophageal dilatation with a patulous gastroesophageal junction 

Structural causes 

•  Oesophageal stricture:
  • Peptic strictures most often typically appear as smooth, tapered narrowing in the distal esophagus
  • Barrett oesophagus occurs often as a consequence of GERD in the mid- to upper esophagus,
  • ring stricture, Schatzki ring is the most common type of esophageal ring, associated with a hiatal hernia
  • other less common causes of benign strictures include corrosive oesophagitis,Crohn disease,  Behçet disease, and eosinophilic esophagitis
• extrinsic mass such as lung cancer, or vascular compression e.g. aberrant right subclavian artery (e.g. dysphagia lusoria)
• esophageal Infections,such as candidiasis, herpes virus, human immunodeficiency virus (HIV), and cytomegalo virus (CMV)
• oesophageal stricturecarcinoma can appear infiltrative, ulcerative, polypoid, and/or varicoid at esophagography
•  impacted foreign body or food bolus in the esophagus. Water-soluble contrast should be used for increased risk of perforation