This article contains a brief atlas for esophageal dysphagia, with an emphasis on endoscopic evaluation. Dysphagia refers to an abnormality with food propulsion, and it may be caused by oropharyngeal or esophageal disorders. Radiological modalities, endoscopy, and manometry play an important role in both the diagnosis and management of esophageal disorders.
Key points
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Dysphagia refers to an abnormality with food propulsion.
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Dysphagia may be caused by oropharyngeal or esophageal disorders.
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Radiological modalities, endoscopy, and manometry play an important role in both the diagnosis and management of esophageal disorders.
Introduction
Dysphagia occurs when there is an abnormality in the propulsion of the ingested bolus during its course from the mouth to the stomach. Difficulties can occur in the oropharyngeal or esophageal phases of swallowing because of functional disorders (dysmotility) or structural lesions (mechanical obstruction) ( Table 1 ).
| Oropharyngeal (Transfer) Dysphagia | Esophageal (Transport) Dysphagia | |
|---|---|---|
| Extrinsic structural obstruction | Cervical osteophytes Goiter Zenker diverticulum Head/neck neoplasm | Vascular compression Mediastinal lesions Cervical osteoarthritis |
| Intrinsic structural obstruction (mucosal/submucosal) | Cricopharyngeal bar Webs Esophageal, pharyngeal neoplasms | Rings/webs Strictures: peptic, malignant Diverticula Esophageal tumors |
| Neuromuscular diseases | Cerebrovascular accident Parkinson disease Multiple sclerosis Amyotrophic lateral sclerosis Myasthenia gravis | Achalasia Abnormal peristalsis (hypercontractility or hypocontractility) Diffuse esophageal spasm Scleroderma |
| Metabolic diseases | Thyroid disease | Thyroid disease Amyloidosis Wilson disease |
| Infectious diseases | Viral/bacterial meningitis Diphtheria | Candidiasis Cytomegalovirus Herpes simplex |
| Rheumatologic diseases | — | Sjögren syndrome Systemic lupus erythematosus Inflammatory myopathies Mixed connective tissue disease Rheumatoid arthritis |
| Iatrogenic causes | Postsurgical anatomic changes Postradiation strictures Medications | Anastomotic strictures Postradiation strictures Medications |
| Miscellaneous | — | Eosinophilic esophagitis |
Oropharyngeal (transfer) dysphagia symptoms include difficult initiation of swallows, food sticking in the upper throat or neck, coughing when swallowing, nasal regurgitation, halitosis, or pain on swallowing (odynophagia). Esophageal (transport) dysphagia symptoms include a lower cervical, suprasternal, or retrosternal location of obstruction to food bolus; odynophagia; chest pain; bland regurgitation; nausea; emesis; heartburn; halitosis; or weight loss. In addition to a thorough history directed to elicit dysphagia as well as other symptoms of associated systemic disease, the diagnostic evaluation includes a barium swallow (esophagogram), Esophagogastroduodenoscopy (EGD), and esophageal manometry. Neck and chest computed tomography (CT) scans and endoscopic ultrasound (EUS) help in the diagnosis of submucosal neoplasms and the staging of malignant tumors.
Introduction
Dysphagia occurs when there is an abnormality in the propulsion of the ingested bolus during its course from the mouth to the stomach. Difficulties can occur in the oropharyngeal or esophageal phases of swallowing because of functional disorders (dysmotility) or structural lesions (mechanical obstruction) ( Table 1 ).
| Oropharyngeal (Transfer) Dysphagia | Esophageal (Transport) Dysphagia | |
|---|---|---|
| Extrinsic structural obstruction | Cervical osteophytes Goiter Zenker diverticulum Head/neck neoplasm | Vascular compression Mediastinal lesions Cervical osteoarthritis |
| Intrinsic structural obstruction (mucosal/submucosal) | Cricopharyngeal bar Webs Esophageal, pharyngeal neoplasms | Rings/webs Strictures: peptic, malignant Diverticula Esophageal tumors |
| Neuromuscular diseases | Cerebrovascular accident Parkinson disease Multiple sclerosis Amyotrophic lateral sclerosis Myasthenia gravis | Achalasia Abnormal peristalsis (hypercontractility or hypocontractility) Diffuse esophageal spasm Scleroderma |
| Metabolic diseases | Thyroid disease | Thyroid disease Amyloidosis Wilson disease |
| Infectious diseases | Viral/bacterial meningitis Diphtheria | Candidiasis Cytomegalovirus Herpes simplex |
| Rheumatologic diseases | — | Sjögren syndrome Systemic lupus erythematosus Inflammatory myopathies Mixed connective tissue disease Rheumatoid arthritis |
| Iatrogenic causes | Postsurgical anatomic changes Postradiation strictures Medications | Anastomotic strictures Postradiation strictures Medications |
| Miscellaneous | — | Eosinophilic esophagitis |
Oropharyngeal (transfer) dysphagia symptoms include difficult initiation of swallows, food sticking in the upper throat or neck, coughing when swallowing, nasal regurgitation, halitosis, or pain on swallowing (odynophagia). Esophageal (transport) dysphagia symptoms include a lower cervical, suprasternal, or retrosternal location of obstruction to food bolus; odynophagia; chest pain; bland regurgitation; nausea; emesis; heartburn; halitosis; or weight loss. In addition to a thorough history directed to elicit dysphagia as well as other symptoms of associated systemic disease, the diagnostic evaluation includes a barium swallow (esophagogram), Esophagogastroduodenoscopy (EGD), and esophageal manometry. Neck and chest computed tomography (CT) scans and endoscopic ultrasound (EUS) help in the diagnosis of submucosal neoplasms and the staging of malignant tumors.
Cervical osteophytes
Cervical osteophytes are common in the elderly population. Bridging anterior osteophytes of the cervical spine are usually caused by diffuse idiopathic skeletal hyperostosis (DISH), also referred to as senile ankylosing hyperostosis , ankylosing vertebral hyperostosis , osteoarthritis , or Forestier disease . The C5-C6 vertebrae levels are the most commonly involved. Cervical osteophytes may cause dysphagia through mechanical obstruction of the esophagus or inflammation causing pharyngitis or periesophagitis. In addition to back or neck stiffness, which is associated with pain, patients report solid food dysphagia and aspiration with swallows. Osteophytes impinging on esophageal lumen can be seen on the barium swallow ( Fig. 1 A ). CT and magnetic resonance imaging (MRI) of the neck (see Fig. 1 B) can be useful to visualize osteophytes and evaluate infection of the larynx and pharyngeal abscess. The treatment is conservative and directed toward antiinflammatory and antibiotic medications. Surgical intervention for the removal of osteophytes is undertaken in a select few patients for treating severe dysphagia and/or dyspnea.
Zenker diverticulum
Zenker diverticulum occurs because of esophageal mucosal and submucosal herniation in the weak area between the transverse fibers of the cricopharyngeus and the oblique fibers of the inferior pharyngeal constrictor (Killian triangle). It is presumed to result from abnormal upper esophageal motility. It is more prevalent in men than women and usually seen in patients aged 60 years and older. The prevalence in the general population is estimated to be 0.01% to 0.11 %. The symptoms include foul breath (halitosis) caused by retained contents in the diverticulum, aspiration, bland regurgitation of food into the mouth, cough, and hoarseness. In some cases, the diverticulum enlarges and encroaches anteriorly into the esophageal lumen causing an extrinsic mechanical obstruction of the upper esophagus. Diagnosis is based on a barium swallow, which shows the contrast retained within the diverticulum ( Fig. 2 A ). Care should be taken when endoscopic examination is attempted (see Fig. 2 B). If the diverticulum is inadvertently intubated instead of the esophageal lumen, further advancing the scope may lead to esophageal perforation.
Symptomatic patients are treated with endoscopic incision or surgical diverticulectomy. The significant surgical morbidity has led to a development of less invasive endoscopic techniques, including the needle-knife technique.
Cricopharyngeal bar
Cricopharyngeal bar refers to the posterior barlike indentation caused by the pharyngoesophageal segment of the upper esophageal sphincter. Barium swallow shows this indentation at the C5-C6 vertebrae level. This finding is usually an incidental radiological finding unless there is severe impingement on the esophageal lumen, which can cause dysphagia ( Fig. 3 ).
Patients aged 60 years and older may report that multiple swallows are required to propel a food bolus and that choking or aspiration occurs during swallows.
Dilation with bougienage or endoscopic injection of botulinum toxin into the cricopharyngeal muscle may relieve dysphagia symptoms. Cricopharyngeal myotomy, an endoscopic or surgical intervention, provides a definitive treatment option for symptomatic patients.
Esophageal neoplasms
Mucosal intraluminal tumors and submucosal polypoid lesions compromise the esophageal lumen, leading to the mechanical obstruction of the swallowed food bolus transit. EGD can be used to view and biopsy mucosal lesions. EUS can evaluate submucosal lesions, and fine-needle aspiration biopsies can be obtained. Squamous and adenocarcinoma are the 2 main histologic types of esophageal cancers. EUS and CT/MRI ( Fig. 4 A ) play a key role in the diagnosis and staging of esophageal tumors. Chronic gastroesophageal reflux disease (GRD) can lead to specialized intestinal metaplasia (Barrett esophagus) and is considered a premalignant condition for esophageal adenocarcinoma (see Fig. 4 B).
