Dysphagia

Abstract

Dysphagia is a symptom that results from the slowing or cessation of a food or liquid bolus as it passes from the oral cavity through the esophagus and into the stomach. An estimated 10 million Americans are evaluated each year with swallowing difficulties in inpatient and outpatient settings. Dysphagia is also associated with significant morbidity, mortality, and healthcare cost. In one study, the average hospital length of stay was almost double for patients with dysphagia when compared with dysphagia-free patients, an estimated cost difference of approximately $547 billion. Aspiration pneumonia, malnutrition, and social embarrassment are common complications of dysphagia and have a significant impact on patients’ overall health and quality of life.

Teaching Questions

• 1. A 74-year-old man is evaluated for intermittent solid food dysphagia. The dysphagia is associated with halitosis and a “gurgling” sensation in his throat after eating. A Zenker’s diverticulum is suspected. Which one of the following is the best initial diagnostic test?

  • (A) Upper endoscopy

  • (B) Esophageal manometry

  • (C) CT scan of the neck

  • (D) Barium esophagography

• 2. A 54-year-old man with uncontrolled hypertension is evaluated in the outpatient setting after presenting to the emergency department twice in the past month with substernal chest pain. Both times, electrocardiograms and troponin levels were normal. He also underwent an exercise stress test which was negative for ischemia. The pain was not reproducible with firm sternal pressure. He states both episodes occurred during dinner and were associated with mild dysphagia. Upper endoscopy was subsequently performed and was normal. Due to a suspicion for a hypercontractile esophageal motility disorder, esophageal manometry was performed and demonstrated simultaneous, high-amplitude, and prolonged esophageal contractions consistent with diffuse esophageal spasm. Which one of the following would be the initial treatment of choice?

  • (A) Long esophagomyotomy

  • (B) Diltiazem

  • (C) Botulinum toxin injection

  • (D) Pneumatic dilatation

• 3. A 27-year-old man with a history of asthma is evaluated for a 6-month history of intermittent solid food dysphagia which is worsened by eating meat and bread. Upper endoscopy demonstrates a “ringed” esophagus, and esophageal biopsies demonstrate 40 eosinophils per high-power field. Ambulatory 24-h combined esophageal pH-impedance testing was negative for gastroesophageal reflux. A diagnosis of eosinophilic esophagitis is made. Which one of the following would be the best choice for initial management?

  • (A) Proton pump inhibitor for 8 weeks followed by repeat endoscopy with biopsies

  • (B) Skin-prick allergy testing with subsequent avoidance of positive reacting food antigens

  • (C) Swallowed topical steroid for 8 weeks

  • (D) Esophageal dilation

• 4. True or false: If a barium esophagram is suggestive of achalasia and the patient is able to maintain their weight and control their symptoms with lifestyle modification, no further evaluation is required.

  • (A) True

  • (B) False

• 5. A 64-year-old woman with a history of gastroesophageal reflux presents to her primary care clinic for evaluation of a 1-year history of episodic solid food dysphagia. She points to the xiphoid area where she feels the food getting “stuck.” The sensation usually abates after taking a few drinks of water; however, she occasionally has to regurgitate the food bolus. Following the episode, she is able to continue eating normally. She denies odynophagia, weight loss, nasal regurgitation, or cough. Which one of the following is the most likely cause of her dysphagia?

  • (A) Peptic stricture

  • (B) Eosinophilic esophagitis

  • (C) Achalasia

  • (D) Zenker’s diverticulum