Dysphagia - Differential Diagnosis Framework



Symptom | Diagnosis

• Solid-food dysphagia present for months to years | Mechanical obstruction: Esophageal web or a distal esophageal ring (Schatzki ring)

• Progressively increasing solid-food dysphagia | Esophageal: Peptic stricture, ring, web or carcinoma. Extrinsic to esophagus: Mediastinal mass, Left atrial size increase

• Solid food and liquid or liquid-only dysphagia | Esophageal motility disorder such as achalasia. Intermittent: Diffuse esophageal spasm



Oropharyngeal Dysphagia ("Transfer dysphagia"):

Difficulty initiating swallowing

• Coughing

• Choking

• Nasal regurgitation of fluids

• Muscular or neurologic disorders, most commonly stroke, Parkinson disease. Other - ALS, Dementia

• Structural - Zenker's, Cervical osteophytes, malignancy



Risk for aspiration pneumonia



Videofluoroscopy is used to evaluate suspected oropharyngeal dysphagia.

Barium swallow is also considered.



Esophageal Dysphagia:

• Can initiate the swallowing process but often feel chest discomfort

• Due to a mechanical obstruction or a motility disorder

• Food “sticking” or discomfort in the retrosternal region

• Bolus slow to go down or “sitting” in the chest

• Mechanical obstruction or a motility disorder



URGENT WORKUP:

• Complete obstruction

• Hematemesis

• Odynophagia

• Onset in an older patient

• Dysphagia associated with weight loss or acute course



Oropharyngeal Dysphagia: Testing

• Videofluoroscopy is used to evaluate suspected oropharyngeal dysphagia

• Barium swallow is also considered



Esophageal Dysphagia: Testing

• Suspected esophageal motility disorder → manometry

• Suspected structural disorder → EGD



Treatment

• Oropharyngeal dysphagia is managed with dietary adjustment and speech therapy.

• Therapy for esophageal dysphagia is dictated by the underlying cause.



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