Dysphagia: Thinking outside the box

Abstract

Dysphagia is a common symptom that is important to recognise and appropriately manage, given that causes include life threatening oesophageal neoplasia, oropharyngeal dysfunction, the risk of aspiration, as well as chronic disabling gastroesophageal reflux (GORD). The predominant causes of dysphagia varies between cohorts depending on the interplay between genetic predisposition and environmental risk factors, and is changing with time. Currently in white Caucasian societies adopting a western lifestyle, obesity is common and thus associated gastroesophageal reflux disease is increasingly diagnosed. Similarly, food allergies are increasing in the west, and eosinophilic oesophagitis is increasingly found as a cause. Other regions where cigarette smoking is still prevalent, or where access to medical care and antisecretory agents such as proton pump inhibitors are less available, benign oesophageal peptic strictures, Barrett's oesophagus, adeno- as well as squamous cell carcinoma are endemic. The evaluation should consider the severity of symptoms, as well as the pre-test probability of a given condition. In young white Caucasian males who are atopic or describe heartburn, eosinophilic esophagitis and gastroesophageal reflux disease will predominate and a proton pump inhibitor could be commenced prior to further investigation. Upper gastrointestinal endoscopy remains a valid first line investigation for patients with suspected oesophageal dysphagia. Barium swallow is particularly useful for oropharyngeal dysphagia, and oesophageal manometry mandatory to diagnose motility disorders.

Keywords: Aspiration; Dysphagia; Eosinophilic; Food bolus impaction; Gastroesophageal reflux; Manometry; Oesophagus.

Figure 1

Anatomy of the oesophagus. Disease of the upper 1/3 of the oesophagus causing dysphagia may include extrinsic compression (e.g., cervical osteophytes), or dysfunction secondary to rheumatological conditions (e.g., Sjogrens’s syndrome) or in eosinophilic oesophagitis (along with the lower oesophagus). The lower oesophagus can be afflicted in scleroderma, gastroesophageal reflux disease and in eosinophilic oesophagitis.

Figure 2

Proposed management algorithm for patients presenting with dysphagia.