Canadian Association of Gastroenterology Practice Guidelines: Evaluation of Dysphagia

Abstract

Dysphagia may be defined as difficulty in swallowing. Dysphagia may be classified as oropharyngeal or esophageal; oropharyngeal dysphagia arises from a structural or functional abnormality in the oropharynx, and esophageal dysphagia occurs as a result of structural or functional abnormalities in the esophagus. Esophageal dysphagia may be further subclassified symptomatically as dysphagia for solids alone, which usually suggests a mechanical problem, versus dysphagia for liquids and solids, which is more suggestive of a neuromuscular problem. Dysphagia may be described by the patient as a sensation of food 'sticking' or as a sensation of food passing slowly through the esophagus. True dysphagia always indicates organic disease and always warrants investigation and consultation if no cause is found in initial studies. These symptoms should be distinguished from those of a persistent foreign body-type sensation or a sensation of a lump, which is more typical of globus sensation. Odynophagia, defined as pain with swallowing, may occur in association with esophageal dysmotility or as a result of mucosal disease in the esophagus.

A 34-year-old man with refractory heartburn and intermittent dysphagia to solids

“…History-taking plays an important role in characterizing dysphagia and narrowing the differential diagnosis, as per the Canadian Association of Gastroenterology dysphagia algorithm. 3 The first step is to ask patients with dysphagia whether they have difficulty initiating a swallow (suggesting oropharyngeal dysphagia) or completing a swallow (suggesting esophageal dysphagia). Patients with oropharyngeal dysphagia may report a history of coughing, choking or nasal regurgita-tion, whereas those with esophageal dysphagia may complain of food sticking.…”

“…Patients with oropharyngeal dysphagia may report a history of coughing, choking or nasal regurgita-tion, whereas those with esophageal dysphagia may complain of food sticking. 3 The next step is to determine whether dysphagia is to solids, liquids or both. Dysphagia to only solids increases the likelihood of a mechanical lesion of the esophagus rather than a neuromuscular disorder.…”

“…Dysphagia to only solids increases the likelihood of a mechanical lesion of the esophagus rather than a neuromuscular disorder. 3 The onset and frequency of dysphagia, particularly whether it has been intermittent or progressive, provides further clues. Rapidly progressive dysphagia is more worrisome for a growing mass.…”

“…Rapidly progressive dysphagia is more worrisome for a growing mass. 3 Other worrisome features of possible malignant disease causing mechanical obstruction in the esophagus include age over 50 and unexplained weight loss. 3 Several features on history-taking may further increase a clinical suspicion of eosinophilic esophagitis.…”

“…3 Other worrisome features of possible malignant disease causing mechanical obstruction in the esophagus include age over 50 and unexplained weight loss. 3 Several features on history-taking may further increase a clinical suspicion of eosinophilic esophagitis. According to a systematic review, patients with eosinophilic esophagitis usually have dysphagia to solids and elaborate coping mechanisms for the dysphagia.…”