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relaxation of the upper oesophageal
sphincter, as well as co-ordinated per-
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Box 1. Causes of oropharyngeal dysphagia |
Box 3. Red flags for malignancy |
flexible videoendoscope through the nose. This allows direct visualisation |
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istaltic contraction and relaxation of circular and longitudinal muscles in the oesophagus to propel the bolus towards the stomach. 12 Activation of inhibitory motor neurons sensitive to stretching results in relaxation of circular muscles distal to contraction, including relaxation of the lower oesophageal sphincter( LOS).
Patients generally define dysphagia as the experience of food / drink being“ stuck” during, or immediately after, the act of swallowing; however, clinicians also seek evidence of impaired bolus transit, such as abnormal delay or incomplete clearance of a liquid or solid bolus from the oral cavity to the stomach. 13
The pathophysiology of dysphagia relates primarily to the phase of
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• Neurological:— Cerebrovascular disease.— Parkinson’ s disease.— Dementia.— Motor neurone disease.— Brainstem disorders.— Myasthenia gravis.— Myopathy, myositis.— Muscular dystrophy.— Guillain – Barre syndrome.
• Mechanical:— Zenker’ s diverticulum, cricopharyngeal bar.— Proximal oesophageal web, stricture.— Carcinoma( eg, base of tongue, pharyngeal, laryngeal).— Pharyngeal or neck infection.— Fibrosis secondary to previous surgery or radiotherapy.— Extrinsic compression from goitre.— Large cervical osteophytes.
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• Onset after age 50.
• Rapidly progressive dysphagia initially to solids and then both solids and liquids.
• Weight loss.
• Odynophagia.
• Anaemia.
• Gastrointestinal bleeding.
• History of smoking / significant alcohol intake or GORD with Barrett’ s oesophagus.
Source: Liu LWC et al 2018 2
The presence of oral candidiasis may indicate oesophageal candidiasis, and poor dentition may be secondary to frequent reflux / regurgitation. 15 Cervical examination aims to exclude an extrinsic compression, such as a
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of the laryngopharynx during swallow. 5 Boluses of various consistencies can be tested to ascertain the aspiration risk, and the location of bolus residue helps guide teaching of swallowing techniques and dietary modification. It is the gold standard for assessment of aspiration. 14
These tests are highly operator dependent and are ideally performed in high-volume centres with greater expertise. 15
ENDOSCOPY Upper endoscopy is performed in most patients who present with dysphagia. It has several advantages over barium study, including direct visualisation of any structural lesions or mucosal abnormalities of the oesoph-
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swallow affected— either oropharyngeal or oesophageal— and whether the problem relates to mechanical obstruction or dysmotility.
Oropharyngeal dysphagia
Oropharyngeal dysphagia is associated
with a delayed or absent swallow initiation and the need for repetitive swallows to clear a bolus from the pharynx. 14 Patients will often report the onset of symptoms immediately on attempting to swallow. 12 There is an increased prevalence with increasing age because of oropharyngeal dysphagia’ s association with neurological disorders, including cerebrovascular disease, Parkinson’ s disease and dementia. 12 Other causes of oropharyngeal dysphagia appear in box 1.
Oesophageal dysphagia
Oesophageal dysphagia refers to a
problem arising after the bolus has passed the upper oesophageal sphinc-
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• Medications:— Centrally acting: benzodiazepines, antihistamines, metoclopramide.— Neuromuscular junction: botulinum toxin, erythromycin, aminoglycosides.— Toxic to muscle: amiodarone, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, ciclosporin.— Inhibition of salivation: anticholinergics, antidepressants, antipsychotics, antiparkinsonian drugs, antihypertensives, diuretics.
— Miscellaneous: digoxin, vincristine. Source: Hurtte E et al 2023 12, Selvanderan S et al 2021 14, Kuo P et al 2012 15
Box 2. Causes of oesophageal dysphagia
• Structural disorders:— Oesophageal web, Schatzki ring.— Benign stricture( secondary to GORD, caustic injury, radiation).— Oesophageal malignancy.— Eosinophilic oesophagitis.— Previous oesophageal surgery( fundoplication, scarring).— Foreign body.— Large hiatus hernia( distortion of oesophageal anatomy).— Extrinsic compression secondary to goitre, vascular abnormality, mediastinal mass.
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goitre, post-radiotherapy changes or the presence of lymphadenopathy that may indicate malignancy or inflammation. 14 Seek obvious signs of rheumatological conditions, such as systemic sclerosis. 16 Perform a cardiovascular examination to exclude risk factors for cerebrovascular disease, including AF and valvular disease, in the appropriate clinical setting. 14
Investigations
Note that not all patients with dysphagia require extensive investigation. 2 If there is initial suspicion of an oropharyngeal cause, it may be appropriate to refer the patient for assessment by a speech pathologist, ENT specialist or neurologist. Equally, if there is strong suspicion of oesophageal dysphagia caused by uncomplicated reflux, it is reasonable to start an empirical trial of a PPI and assess the response. 2
The three main investigations per-
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agus, the ability to obtain biopsies for histological diagnosis and the ability to perform therapeutic interventions, such as dilation of strictures. 2, 5, 6 Endoscopy may be normal in motility disorders, such as achalasia; however, there is often a tight gastro-oesophageal junction and a dilated oesophagus with associated food / fluid residue. 14
The use of upper endoscopy is becoming more common thanks to wider availability across the metropolitan regions, the rise of eosinophilic oesophagitis that can only be diagnosed on oesophageal biopsy, and improved equipment and procedural technique that allows for increased therapeutic applications with reduced procedure-related complications.
The main drawback of endoscopy is its relatively invasive nature and the associated sedation / anaesthetic risks, which occur mainly in patients
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ter and can be broadly categorised into structural abnormalities and
12, 14 motility disorders( see box 2). Structural abnormalities may result from luminal narrowing from either extrinsic compression or intrinsic pathology, such as stricture, malignancy or mucosal inflammation— for example, due to eosinophilic oesophagitis. 2, 6
Motility disorders generally arise from an abnormality in neuromuscular function, predominantly affecting oesophageal body peristalsis and LOS relaxation. 6
CLINICAL EVALUATION
History
TAKING a detailed and accurate his-
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• Motility disorders:— Primary:
• Achalasia.
• Oesophagogastric junction outflow obstruction.
• Distal oesophageal spasm.
• Hypercontractile oesophagus.
• Oesophageal hypomotility( ineffective oesophageal motility, absent contractility).
— Secondary:
• Systemic sclerosis and other connective tissue disorders.
• Chagas disease.
• Pseudoachalasia( mechanical obstruction, infiltration or paraneoplastic).
• Medications, including opioids, calcium-channel blockers, nitrates( including phosphodiesterase inhibitors), anticholinergics, antiepileptics, benzodiazepines.
Source: Hurtte E et al 2023 12, Selvanderan S et al 2021 14, Kuo P et al 2012 15
of swallowing and disappears during
course, particularly in association
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formed for dysphagia remain video barium swallow, endoscopy and oesophageal manometry +/- oesophageal reflux monitoring. 6 The choice of test / s to perform depends on the suspected underlying problem, patient factors and accessibility of the test.
BARIUM SWALLOW Barium swallow( see figure 1) is often the first test performed in primary care given it is generally easily accessible, minimally invasive and inexpensive. 14, 15 The patient ingests liquid barium or, less commonly, barium-soaked solids, such as bread, when specifically requested. An X-ray is then performed to track the passage of the bolus from the oral cavity to the stomach.
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with extreme frailty and those with anatomical distortion of the upper digestive tract. 1 The risk of bleeding is about 1 %, and the risk of infection is 0-8 %. 17 The risk of perforation is one in 10,000, but this increases to 1-2 % if dilation of a stricture is performed. 15 Endoscopy is less sensitive for the detection of abnormalities close to the upper oesophageal sphincter, including Zenker’ s diverticulum or a proximal oesophageal web, because of reduced visualisation. 5
OESOPHAGEAL MANOMETRY High-resolution manometry( see figure 2) is generally considered a second-line test after mechanical obstruction has been excluded by endoscopy or barium study. It is the
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tory will help determine the nature of the pathology as either oropharyngeal or oesophageal, as well as delineate the likely underlying cause in up to 85 % of cases. This will allow the formulation of a subsequent investiga- |
meal consumption. Xerostomia( oral dryness) can result in difficulty swallowing because of inadequate lubrication of the bolus. 14
Dysphagia commonly presents with associated regurgitation or vom-
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with weight loss, raises suspicion for a neoplastic process( see box 3), whereas benign pathologies, such as a peptic stricture, are more likely to be static or slowly progressive. 14 Identifying underlying risk factors |
It is particularly useful if there is concern for an oropharyngeal cause or structural abnormality or if there is uncertainty regarding the patient’ s fitness for an endoscopy. 2, 6 The procedure is useful to assess oropharyngeal |
gold standard for diagnosing motility disorders of the oesophagus. 6 A thin manometry catheter with closely spaced pressure sensors, 1cm apart along its length, is inserted transnasally into the oesophagus with |
tion and management plan. 2, 15 Distinguish dysphagia from commonly associated symptoms, includ- |
iting, cough or food bolus obstruction. 16 Localisation of the site of hold-up of the bolus may corre- |
for particular aetiologies, including comorbid conditions, is also important. |
co-ordination and potential aspiration and to detect a Zenker’ s diverticulum, oesophageal webs and rings, |
the aid of topical local anaesthetic, such that the distal tip is positioned just below the diaphragm. With the |
ing odynophagia( defined as pain during swallowing) and globus( defined as a constant sensation of tightness or a foreign body sensation |
late with the site of pathology— for example, a retrosternal sensation may relate to oesophageal pathology, while throat or cervical localisation |
Physical examination
The detail of the physical examination
is largely determined by the
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other strictures and mass lesions; however, it is less sensitive for diagnosing oesophageal dysmotility. 15 A standard barium swallow is contrain- |
patient supine, they are instructed to perform 10 swallows of 5mL water boluses. 18
Solid and semi-solid trials may
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in the throat or neck). |
may correspond to oropharyngeal |
perceived cause, based on the his- |
dicated when there is any suspicion |
also be included, and testing can be |
Odynophagia may be secondary to inflammation or infection in the throat or oesophagus, whereas globus |
pathology. 15 However, such localisation can be inaccurate, with retrosternal local- |
tory. Examination of the oral cavity and cervical region is important in assessing oropharyngeal dyspha- |
of oesophageal perforation or for postoperative assessment of anastomotic leak, and there is a relative con- |
performed upright if there is a significant risk of aspiration. 15 This technique can be combined with |
is considered to result from increased |
isation being more reliable than |
gia; however, physical examination |
traindication in patients with a high |
oesophageal impedance monitoring |
perception of, and hypervigilance to, |
localisation to the throat and neck. |
is generally unhelpful in oesopha- |
aspiration risk. 5 |
to determine whether the dysmotil- |
sensations in the area— often without any bolus present. 12 One unique characteristic of globus, as opposed to true dysphagia, is that the symptom is often persistent and independent |
Dysphagia affecting solids only is also more suggestive of a mechanical obstruction, while motility disorders tend to affect both solids and liquids. 14 A rapidly progressive |
geal dysphagia apart from as a marker of severity if signs of weight loss or malnutrition are present. 14, 16 A neurological examination is also important in oropharyngeal dysphagia. 15 |
Speech pathologists generally perform a modified barium swallow using videofluoroscopy and fibre-optic endoscopic evaluation of swallowing involving the use of a small |
ity has a significant impact on bolus transit and helps to correlate with symptoms. 15
The Chicago Classification, currently in its fourth version, is an
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