Chapter 038. Dysphagia (Part 5)

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Diseases of the striated muscle often also involve the cervical part of the esophagus, in addition to affecting the oropharyngeal muscles. Clinical manifestations of the cervical esophageal involvement are usually overshadowed by those of the oropharyngeal dysphagia. Diseases of the smooth-muscle segment involve the thoracic part of the esophagus and the LES. Dysphagia occurs when the peristaltic contractions are weak or absent or when the contractions are nonperistaltic. Loss of peristalsis may be associated with failure of LES relaxation. Weakness of contractile power occurs due to muscle weakness, as in scleroderma or impaired cholinergic effect. Nonperistaltic contractions and failure of...

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Chapter 038. Dysphagia (Part 5) Diseases of the striated muscle often also involve the cervical part of the esophagus, in addition to affecting the oropharyngeal muscles. Clinical manifestations of the cervical esophageal involvement are usually overshadowed by those of the oropharyngeal dysphagia. Diseases of the smooth-muscle segment involve the thoracic part of the esophagus and the LES. Dysphagia occurs when the peristaltic contractions are weak or absent or when the contractions are nonperistaltic. Loss of peristalsis may be associated with failure of LES relaxation. Weakness of contractile power occurs due to muscle weakness, as in scleroderma or impaired cholinergic effect. Nonperistaltic contractions and failure of LES relaxation occur due to impaired inhibitory innervation. In diffuse esophageal spasm (DES), inhibitory innervation only to the esophageal body is impaired, whereas in achalasia inhibitory
innervation to both the esophageal body and LES is impaired. Dysphagia due to esophageal muscle weakness is often associated with symptoms of gastroesophageal reflux disease (GERD). Dysphagia due to loss of the inhibitory innervation is typically not associated with GERD but may be associated with chest pain. The causes of esophageal motor dysphagia are also listed in Table 38-2; they include scleroderma of the esophagus, achalasia, DES, and other motor disorders. Approach to the Patient: Dysphagia Figure 38-1 shows an algorithm of approach to a patient with dysphagia.
Approach to the patient with dysphagia. ENT, ear, nose, and throat; VFSS, videofluoroscopic swallowing study. HISTORY The history can provide a presumptive diagnosis in >80% of patients. The site of dysphagia described by the patient helps to determine the site of esophageal obstruction; the lesion is at or below the perceived location of dysphagia. Associated symptoms provide important diagnostic clues. Nasal regurgitation and tracheobronchial aspiration with swallowing are hallmarks of pharyngeal paralysis or a tracheoesophageal fistula. Tracheobronchial aspiration
unrelated to swallowing may be due to achalasia, Zenker's diverticulum, or gastroesophageal reflux. Association of laryngeal symptoms and dysphagia occurs in various neuromuscular disorders. The presence of hoarseness may be an important diagnostic clue. When hoarseness precedes dysphagia, the primary lesion is usually in the larynx; hoarseness following dysphagia may suggest involvement of the recurrent laryngeal nerve by extension of esophageal carcinoma. Sometimes hoarseness may be due to laryngitis secondary to gastroesophageal reflux. Hiccups may rarely occur with a lesion in the distal portion of the esophagus. Unilateral wheezing with dysphagia may indicate a mediastinal mass involving the esophagus and a large bronchus. The type of food causing dysphagia provides useful information. Difficulty only with solids implies mechanical dysphagia with a lumen that is not severely narrowed. In advanced obstruction, dysphagia occurs with liquids as well as solids. In contrast, motor dysphagia due to achalasia and DES is equally affected by solids and liquids from the very onset. Patients with scleroderma have dysphagia to solids that is unrelated to posture and to liquids while recumbent but not upright. When peptic stricture develops in patients with scleroderma, dysphagia becomes more persistent.
The duration and course of dysphagia are helpful in diagnosis. Transient dysphagia may be due to an inflammatory process. Progressive dysphagia lasting a few weeks to a few months is suggestive of carcinoma of the esophagus. Episodic dysphagia to solids lasting several years indicates a benign disease characteristic of a lower esophageal ring. Severe weight loss that is out of proportion to the degree of dysphagia is highly suggestive of carcinoma.