“How long has this been occurring? Is it getting worse? Do you hesitate to go out to eat because of it?”Īcute symptoms may be caused by pill esophagitis, infection, or foreign body impaction. Trouble initiating a swallow, choking, coughing, or nasopharyngeal regurgitation suggests oropharyngeal dysphagia. “What happens when you swallow? Does swallowing make you cough?”įeeling that food is stuck suggests esophageal origin, regardless of the perceived location. Malignancy (esophageal or gastric cancer, mediastinal mass with extrinsic compression)Įsophagogastric junction outflow obstructionĮffective initial question for screening as effective as longer screening instruments for prompting further questioning. Reflux caused by decreased tone of lower esophageal sphincter (associated with alcohol, anticholinergics, benzodiazepines, caffeine, calcium channel blockers, nitrates, and tricyclic antidepressants)Įsophageal or peptic stricture (caused by erosive esophagitis)įoreign body or food impaction (acute-onset dysphagia) Pill esophagitis (direct irritation associated with ascorbic acid, bisphosphonates, ferrous sulfate, nonsteroidal anti-inflammatory drugs, potassium chloride, quinidine, and tetracyclines) Gastroesophageal reflux disease (nonerosive) Gastroesophageal reflux disease and esophagitis (30% to 40%)įunctional esophageal disorders (20% to 30%) † 22, 43Įxpert consensus on dysphagia as a geriatric syndrome Older patients with chronic illness or recent pneumonia should be screened for dysphagia if it is present, the physician and patient should discuss goals of care. 15, 17Įxpert consensus recommendation based on CAG, ACG, and AGA guidelines early-stage eosinophilic esophagitis may not exhibit mucosal changes on endoscopy 9, 29, 30ĬAG, STS, and WGO guidelines expert consensus based on limited evidence and cost-analysis EGD has greater sensitivity and specificity than barium esophagography, with greater cost-effectivenessįor accurate diagnosis of eosinophilic esophagitis, biopsies from normal-appearing mucosa in the midthoracic and distal esophagus should be requested for all patients with unexplained solid food dysphagia. Retrospective review of 3,668 consecutive patients distal esophageal pathology was incorrectly perceived as arising from the neck or throat in 15% to 30% of casesĮGD is recommended for the initial assessment of patients with esophageal dysphagia barium esophagography is recommended as an adjunct if EGD findings are negative. Patients with apparent oropharyngeal symptoms but a negative evaluation should be referred for EGD to rule out esophageal pathology. 9, 26, 27ĬAG and ACG guidelines systematic review of seven retrospective cohort studies showing a positive predictive value of less than 1% for malignancy Patients younger than 50 years who have esophageal dysphagia and no other worrisome symptoms should undergo a four-week trial of acid suppression therapy before endoscopy is performed. Speech-language pathologists and other specialists, in collaboration with family physicians, can provide structured assessments and make appropriate recommendations for safe swallowing, palliative care, or rehabilitation. In these patients, the diagnosis of dysphagia should prompt a discussion about goals of care before potentially harmful interventions are considered. Many frail older adults with progressive neurologic disease have significant but unrecognized dysphagia, which significantly increases their risk of aspiration pneumonia and malnourishment. Esophageal cancer and other serious conditions have a low prevalence, and testing in low-risk patients may be deferred while a four-week trial of acid-suppressing therapy is undertaken. Esophagogastroduodenoscopy is recommended for the initial evaluation of esophageal dysphagia, with barium esophagography as an adjunct. Opioid-induced esophageal dysfunction is becoming more common. Esophageal motility disorders such as achalasia are relatively rare and may be overdiagnosed. Eosinophilic esophagitis is triggered by food allergens and is increasingly prevalent esophageal biopsies should be performed to make the diagnosis. This condition is most commonly caused by gastroesophageal reflux disease and functional esophageal disorders. Patients with esophageal dysphagia may report a sensation of food getting stuck after swallowing. Symptoms should be thoroughly evaluated because of the risk of aspiration. Oropharyngeal dysphagia manifests as difficulty initiating swallowing, coughing, choking, or aspiration, and it is most commonly caused by chronic neurologic conditions such as stroke, Parkinson disease, or dementia. Obstructive symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions. Specific symptoms, rather than their perceived location, should guide the initial evaluation and imaging. Dysphagia is common but may be underreported.
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