Chapter 038. Dysphagia (Part 6)

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Chest pain with dysphagia occurs in DES and related motor disorders. Chest pain resembling DES may occur in esophageal obstruction due to a large bolus. A prolonged history of heartburn and reflux preceding dysphagia indicates peptic stricture. A history of prolonged nasogastric intubation, ingestion of caustic agents, ingestion of pills without water, previous radiation therapy, or associated mucocutaneous diseases may provide the cause of esophageal stricture. If odynophagia is present, candidal, herpes, or pill-induced esophagitis should be suspected. In patients with AIDS or other immunocompromised states, esophagitis due to opportunistic infections such as Candida, herpes simplex virus, or cytomegalovirus and...

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Chapter 038. Dysphagia (Part 6) Chest pain with dysphagia occurs in DES and related motor disorders. Chest pain resembling DES may occur in esophageal obstruction due to a large bolus. A prolonged history of heartburn and reflux preceding dysphagia indicates peptic stricture. A history of prolonged nasogastric intubation, ingestion of caustic agents, ingestion of pills without water, previous radiation therapy, or associated mucocutaneous diseases may provide the cause of esophageal stricture. If odynophagia is present, candidal, herpes, or pill-induced esophagitis should be suspected. In patients with AIDS or other immunocompromised states, esophagitis due to opportunistic infections such as Candida, herpes simplex virus, or cytomegalovirus and to tumors such as Kaposi's sarcoma and lymphoma should be considered.
PHYSICAL EXAMINATION Physical examination is important in oral and pharyngeal motor dysphagia. Signs of bulbar or pseudobulbar palsy, including dysarthria, dysphonia, ptosis, tongue atrophy, and hyperactive jaw jerk, in addition to evidence of generalized neuromuscular disease, should be sought. The neck should be examined for thyromegaly or a spinal abnormality. A careful inspection of the mouth and pharynx should disclose lesions that may interfere with passage of food. Pulmonary complications such as acute or chronic aspiration pneumonia may be present. Physical examination is often unrevealing in esophageal dysphagia. Changes in the skin and extremities may suggest a diagnosis of scleroderma and other collagen vascular diseases or mucocutaneous diseases such as pemphigoid or epidermolysis bullosa, which may involve the esophagus. Cancer spread to lymph nodes and liver may be evident. DIAGNOSTIC PROCEDURES
Dysphagia is usually a symptom of organic disease rather than a functional complaint. If oral or pharyngeal dysphagia is suspected, VFSS by both a radiologist and a swallow therapist is the procedure of choice. Videoendoscopy is currently performed only in specialized centers. Otolaryngoscopic and neurologic evaluation are also usually required. If esophageal mechanical dysphagia is suspected on clinical history, barium swallow and esophagogastroscopy with or without mucosal biopsies are the diagnostic procedures of choice. In some cases, CT examination and endoscopic ultrasound may be useful. For motor esophageal dysphagia, barium swallow, esophageal manometry, esophageal pH, and impedance testing are useful diagnostic tests. Esophagogastroscopy is also often performed in patients with motor dysphagia to exclude an associated structural abnormality (Chap. 286). Further Readings Massey B, Shaker R: Oral pharyngeal and upper esophageal sphincter motility disorders. www.GImotilityonline.com; doi:10.1038/gimo19, 2006 McCullough TM, Jaffe D: Head and neck disorders causing dysphagia.
www.GImotilityonline.com; doi:10.1038/gimo36, 2006 Paterson WG et al: Esophageal motility disorders. www.GImotilityonline.com; doi:10.1038/gimo20, 2006 Bibliography Achem SR, DeVault KR: Dysphagia in aging. J Clin Gastroenterol 39:357, 2005 [PMID: 15815202] Gramigna GD: How to perform videofluoroscopic swallowing studies. www.GImotilityonline.com; doi:10.1038/gimo95, 2006 Logemann JA: Medical and rehabilitative therapy of oral and pharyngeal motor disorders. GI Motility Online, http://www.nature.com/gimo/contents/pt1/full/gimo50.html, 2006