creation date: 2026-05-30 18:07
tags: Workups
Dysphagia
Background
Dysphagia refers to a subjective sensation of difficulty or abnormality of swallowing. Acute onset requires immediate attention.
Dysphagia is categorized by oropharyngeal dysphagia (upper esophagus and pharynx) or esophageal dysphagia.
While aging may result in mild esophageal motility abnormalities, these are rarely symptomatic and thus dysphagia should not be attributed to the normal aging process.
Odynophagia refers to painful swallowing.
Globus sensation referes to a nonpainful sensation of a lump, tightness, or foreign body/retained food in the pharyngeal or cervical area. A functional disorder characterized by this sensation without an underlying abnormality is known as globus.
Pathophysiology
Swallowing involves a series of events for food to travel from the oral cavity to the stomach.
The initial process from the oral cavity to the pharynx is a voluntary process. Involving coordinated contraction of oropharyngeal muscles. Mastication is also often necessary for larger solids.
The process from the oropharynx through the esophagus to the stomach is an involuntary process. A number of disorders can affect this from neurological, musclular, mechanical, infectious, and inflammatory causes.
Differential Diagnosis
Acute dysphagia
- Food impaction is the most common cause (often meat)
Non-acute dysphagia
Oropharyngeal dysphagia:
- Disorders impairing oral preparation of food
- Poor dentition
- Decreased salivary flow (eg. Sjogren’s disease, anticholinergics)
- Reduced swallowing reflex (post-stroke
- Parkinson (lingual pumping)
- Disruption of mucosa inhibiting normal processing
- Disorders of pharyngeal phase
- Neurologic disorders causing muscle dystrophy
- Poor compliance of upper esophageal sphincter (Parkinson’s, primary cricopharyngeal dysfunction)
- Obstructions due to malignancy or other lesions
Esophageal dysphagia (categorized by symptoms):
- Solids only with progressive symptoms
- Esophageal stricture (commonly due to GERD, healing from erosive esophagitis; less common due to radiation)
- Carcinoma (of esophagus or gastric cardia; associated with chest pain, odynophagia, anemia, anorexia, weight loss)
- Solids only with intermittent symptoms
- Eosinophilic esophagitis (endoscopy: stacked circular rings, strictures, linear furrows, white papules, small calibre esophagus)
- Esophageal webs and rings
- Cardiovascular abnormality (causing esophagus compression)
- Liquids alone or both liquids/solid dysphagia
- Achalasia (loss of normal peristalsis and lower esophageal sphincter relaxation failure)
- Esophagogastric junction (EGJ) outflow obstruction (failed or incomplete opening)
- Peristalsis disorders (spasm, hypercontractility, ineffective motility)
- Systemic sclerosis (scleroderma; esophageal involvement in 90% of cases)
- Functional dysphagia (rule out other causes)
- Odynophagia and dysphagia
- Infectious esophagitis (HSV, cytomegalovirus, Candida spp.)
- Medication-induced esophagitis (pill lodged in esophagus)
- Reflux esophagitis
- Esophageal Crohn disease
Initial Evaluation
History
Initial history should distinguish oropharyngeal from esophageal dysphagia.
Oropharyngeal dysphagia:
- Difficulty initiating swallow
- Food stuck immediately after swallow
- Nasopharyngeal regurgitation, aspiration, sensation of residual food in pharynx
- Oral dysfunction (eg. drooping, food spillage)
- Pharyngeal dysfunction (eg. coughing, choking, dysphonia)
Esophageal dysphagia:
- Difficulty swallowing several seconds after initiating swallow
- Sensation of foods and/or liquids obstructed or delayed in passage from upper esophagus to stomach
Additional symptoms characterizes the dysphagia:
- Solid, liquid, or both
- Progressive (started with solids then to liquid) or intermittent
- Other findings such as heart burn, weight loss, hematemesis, anemia, regurgitation, and respiratory symptoms
Physical Exam
An examination of the following should be performed:
- Oropharyngeal (for dentition, lip closure, mucosal changes, neurological changes)
Investigations
Obtain an initial barium esophagram for patients with risk factors of a complex stricture or proximal esophageal lesion:
- History of radiation to area
- History of caustic esophageal injury
- History of complex esophageal stricture
- Prior surgery for laryngeal or esophageal cancer
- Symptoms for Zenker’s diverticulum
All patients should receive an upper endoscopy for structural abnormality. Patients without findings should undergo high resolution esophageal manometry for findings suggestive of motility disorders.