Dysphagia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Feham Tariq, MD [2], Hamid Qazi, MD, BSc [3]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Feham Tariq, MD [2], Ajay Gade MD[3]], Hamid Qazi, MD, BSc [4]

Dysphagia derives from the Greek root dys meaning difficulty or disordered, and phagia meaning “to eat”. In 1800, Dr. Patrick Paterson reported a case of gangrenous stomach with dysphagia from lightening. In 1811, Dr. TJ Armiger reported a case of aortic aneurysm causing dysphagia. In 1978, Landres et al reported an isolated case of vigorous achalasia and concluded that this was a variant of eosinophilic gastroenteritis in a patient with marked hypertrophy and eosinophilic infiltration of esophagus. In 1981, Picus and Frank reported a case of a 16-year-old boy with progressive dysphagia for 1.5 years, endoscopic findings were suggestive of multiple 1-mm nodular filling defects in the esophagus in an area of stricture with dilatation above. In 1982, Münch et al and in 1983, Matzinger and Daneman both described isolated cases of esophageal eosinophilia with dysphagia in patients with assumed eosinophilic gastroenteritis. In 1989, Attwood et al described esophageal asthma, an episodic dysphagia with eosinophilic infiltrates. In 1993, Attwood et al reported 12 adults with dysphagia, normal pH monitoring, and dense esophageal eosinophilia. Seven patients had food hypersensitivity, and all required advanced intervention (dilatation and/or steroids in 1 case) for resolution of symptoms. In 1994, Straumann et al described a series of 10 patients with acute recurrent dysphagia seen over a 4-year period.

The historical perspective of dysphagia is as follows:^{[1][2][3][4][5][6][7][8][9]}

• In 1800, Dr. Patrick Paterson reported a case of gangrenous stomach with dysphagia from lightening.
• In 1811, Dr. TJ Armiger reported a case of aortic aneurysm causing dysphagia.
• In 1911, Dr. Walter Howarth reported a case of laryngeal Tuberculosis leading to dysphagia.
• In 1978, Landres et al reported an isolated case of vigorous achalasia and concluded that this was a variant of eosinophilic gastroenteritis in a patient with marked hypertrophy and eosinophilic infiltration of esophagus.
• In 1981, Picus and Frank reported a case of a 16-year-old boy with progressive dysphagia for 1.5 years, endoscopic findings were suggestive of multiple 1-mm nodular filling defects in the esophagus in an area of stricture with dilatation above.
• In 1982, Münch et al and in 1983, Matzinger and Daneman both described isolated cases of esophageal eosinophilia with dysphagia in patients with assumed eosinophilic gastroenteritis.
• In 1989, Attwood et al described esophageal asthma, an episodic dysphagia with eosinophilic infiltrates.
• In 1993, Attwood et al reported 12 adults with dysphagia, normal pH monitoring, and dense esophageal eosinophilia. Seven patients had food hypersensitivity, and all required advanced intervention (dilatation and/or steroids in 1 case) for resolution of symptoms.
• In 1994, Straumann et al described a series of 10 patients with acute recurrent dysphagia seen over a 4-year period. These patients showed discrete endoscopic changes, and high concentrations of epithelial esophageal eosinophils. They improved following systemic steroid and antihistamine treatment.

• In 1988, Fibreoptic endoscopic evaluation of swallowing (FEES) evolved as a valid, low-cost, and quick bedside technique for the evaluation of dysphagia among different hospital settings and all age groups.^[10][11]

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Dysphagia may be classified based on the location into oropharyngeal dysphagia or esophageal dysphagia. Dysphagia may also be classified based on etiology into further six subclasses which include infectious, metabolic, myopathic, neurological, structural and, iatrogenic.

Dysphagia may be classified based on the location into two major types:^[1][2][3]

• Oropharyngeal dysphagia
• Esophageal dysphagia

Dysphagia can also be classified based on the etiology into six sub classes:

• Infectious
• Metabolic
• Myopathic
• Neurological
• Structural
• Iatrogenic

• Arises from abnormalities of the upper esophagus, pharynx, and oral cavity.

• Arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach.
• Most commonly esophageal dysphagia is either due to mechanical obstruction of esophageal lumen or motility problems.

• Dysphagia due to no organic cause.
• Diagnosis of exclusion.

Classification of Dysphagia

Based on etiology

Based on location

Metabolic

Infectious

Myopathic

Neurological

Structural

Iatrogenic

•Amyloidosis •Cushings syndrome •Thyrotoxicosis •Wilsons disease

• Mucositis •Diphtheria •Botulism •Lymes disease •Syphilis

•Connective tissue disease •Dermatomyositis •Myasthenia gravis •Myotonic dystrophy • Polymyositis •Sarcoidosis •Paraneoplastic syndromes

•Brainstem tumors •Head trauma • Stroke • Cerebral palsy • Gullian barre syndrome • Huntington disease • Multiple sclerosis • Postpolio syndrome • Tardive dyskinesia • Metabolic encephalopathies • Amyotrophic lateral sclerosis • Parkinson’s disease • Dementia

• Cricopharyngeal bar • Zenkers diverticulum • Cervical webs • Oropharyngeal tumors • Osteophytes and skeletal abnormalities •Congenital(cleft palate,diverticula,pouches)

•Medication side effects(neuroleptics) • Radiation •Corrosive(pill injury,intentional) •Postsurgical muscular or neurogenic

Esophageal dysphagia

Oropharyngeal dysphagia

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Dysphagia can result from propulsive failure, motility disorders, structural disorders, intrinsic or extrinsic compression of the oropharynx or esophagus. Propulsive failure can result from dysfunction of the central nervous system control mechanisms, intrinsic musculature, or peripheral nerves. Structural abnormalities may result from surgery, neoplasm, caustic injury, or congenital anomalies.

Normal physiology of swallowing can be discussed under three phases:^[1][2][3][4]

• Preparatory phase:
  • Preparatory phase involves mastication and formation of a bolus in the oral cavity.
• Voluntary phase:
  • Voluntary phase is characterized by propelling the bolus into the pharyngeal phase.
  • Voluntary phase is controlled by
    • Corticobulbar tracts
    • Cranial nerves V, VII, and XII.

• Pharyngeal phase is a reflex mechanism and is controlled by the cranial nerves V, X, XI, and XII.

• Once the bolus reaches esophageal phase, esophagus is responsible for moving the bolus along the upper gastrointestinal tract to initiate the process of digestion by delivering it to stomach.^[5]
• The esophagus has anti-reflux barrier which prevents the return of the acidic contents of the stomach back to the esophagus.
• The anti-reflux barrier is formed by the lower esophageal sphincter (LES) and a part of the diaphragm.
• The lower esophageal sphincter is contracting smooth muscle located at the end of the esophagus.
• Due to it’s high pressure tone LES, acts as a strong barrier between the esophagus and the stomach contents.

Physiological dysphagia occurs as a result of normal aging. Normal aging results in certain changes that affect the swallowing mechanism which include:^{[6][7][8][9][10]}

• Reduced lingual movement.
• Delayed onset of the pharyngeal swallow.
• Delayed upper esophageal sphincter relaxation during swallowing.
• Diminished pharyngo–laryngeal response.
• Decreased nerve function.
• Decline in muscle mass.

Pathological dysphagia can occur as a result of the following mechanisms.

• Esophageal lumen can be narrowed by the following factors:^{[11][12][13][14]}
  • Stricture
  • Inflammation
  • Esophageal webs
  • Malignancy

• Majority of the patients that present with dysphagia will have normal investigation findings.
• Normal findings suggests a somato-sensory dysfunction rather than neuro-muscular cause of dysphagia.^[15]
• Non-obstructive causes of dysphagia include:
  • Motility disorders of esophagus
  • Rheumatological conditions
  • Medication induced dysphagia
  • Neurological disorders

• Motility disorder of esophagus occurs when there is an imbalance between inhibitory and excitatory neurons of the myenteric plexus at the distal esophageal sphincter.^{[16][17][18][19]}
• This imbalance results in a decrement of inhibitory innervation leading to aperistalsis.^[20]
• Reduced inhibitory innervation also leads to failure of relaxation of the lower esophageal sphincter resulting in difficulty in swallowing (dysphagia).^[21]

• The smooth muscle of the mid and lower esophagus is replaced by fibrous tissue secondary to the underlying autoimmune pathology leading to incompetence of the lower esophageal sphincter (LES) and subsequently to GERD and dysphagia.^[22][23]

• Most common rheumatological conditions associated with dysphagia include:
  • CREST syndrome^[24]
  • Sjogren’s syndrome^[25]
  • Systemic lupus erythematosus (SLE)
  • Mixed connective tissue disease (MCTD)
  • Rheumatoid arthritis

• Medications can contribute to dysphagia by making peristalsis difficult either by:^{[26][27][28][29]}
  • Decreasing the strength of lower esophageal sphincter relaxation.
  • Reducing the lubrication of esophageal lumen by decreasing the salivary secretions.
• Some medications also have a local or systemic immunosuppressant effect can predispose to infective oesophagitis.
  • Antipsychotics,^[30]
  • Tricyclic antidepressant
  • Anticholinergic
  • Opioids
  • Iron supplements
  • Potassium supplements
  • NSAIDs
  • Tetracyclines
  • Macrolides
  • Bisphosphonates
  • Calcium channel blockers
  • Nitrates
  • Alcohol
  • Theophylline

• Neurological disorders predominanlty affect the oropharyngeal phase. However, pharyngeal phase of swallowing can also be involved in cases of stroke affecting the basal ganglia and the cortex, as it affects the ability to initiate the swallow and decrement in bolus transit between pharynx and esophagus.^[31][32][33]
• Neurological deficits can cause weakness of the oral musculature and tongue movements resulting in failure to form a intact food bolus and decreased sensitivity of the pharyngeal receptors, subsequent to neurological compromise leading to dysphagia.
• The central, autonomic or peripheral nervous system is affected by several neurological diseases such as:
  • Parkinsons disease
  • Myasthenia gravis
  • Motor neuron disease
  • Cerebrovascular accident
  • Multiple sclerosis

The following genes can be involved in the development of dysphagia subsequent to different pathologies:

• ACD

• CTC1

• DKC1 

• NHP2

• NOP10

• PARN

• RTEL1

• TERC

• TERT

• TINF2

• WRAP53

Mutations in the following genes can cause esophageal cancer:

• Chromosomal losses (4q, 5q, 9p, and 18q)
• Chromosomal gains (8q, 17q, and 20q)
• Gene amplifications (7, 8, and 17q)
• PT53 genes and P16 genes 
• Variants in ADH and/or ALDH2 genes

• HLA class II molecules
• Vasoactive intestinal peptide
• KIT
• Interleukin 23 receptor

Common conditions associated with dysphagia include:

• Peptic stricture
• Esophageal rings and webs
• Esophageal cancer
• Achalasia
• Spastic motility disorders
• Diffuse esophageal spasm
• Nutcracker esophagus
• Hypertensive lower esophageal sphincter
• Nonspecific spastic esophageal motility disorders

The gross morphology of dysphagia depends on the underlying pathologic condition. Following are the gross morphologic features of some important causes of dysphagia:

Zenkers diverticulum:

• Diverticulum or a sac is seen in the esophagus

Esophageal stricture:

• Pale mucosa with white exudate in lymphocytic esophagitis

• Swelling and hemorrhagic congestion in caustic ingestion

• Multiple yellow plaques in infectious esophagitis due to Candida

• Ulceration of the esophagus in viral esophagitis

Esophageal cancer:

Squamous cell carcinoma or adenocarcinoma of the esophagus may appear as:

• Flat and irregular plaque

• Polypoid lesion 

• Ulcerating, fungating mass.
• Location:
• Squamous cell carcinoma is usually found in the mid-third of the esophagus.
• Adenocarcinomais usually found in the lower third of the esophagus near the gastric opening.

Achalasia:

• There is defect in the nerves that control the motility of the esophagus (the myenteric plexus). 
• The esophagus is dilated and hypertrophied.

Diffuse esophageal spasm(DES):

Gross thickening of muscularis propria layer and lower esophageal sphincter (LES) due to hyperplasia are characteristic findings of DES.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Feham Tariq, MD [2]Kiran Singh, M.D. [3]

Dysphagia can be caused by many diseases such as neurological disorders, structural disorders of esophagus, tumors and motor disorders.

Depending upon the type of dysphagia, causes can be categorized into two subsections.^[1][2][3][4]

Common causes of oropharyngeal dysphagia
Neurological	Medication side effects	Others
Stroke Parkinson’s disease Occulopharyngeal dystrophy Amyotrophic lateral sclerosis Myasthenia gravis	Sedatives Hypnotic agents Anticonvulsants Neuroleptics Antihistamines Barbiturates Antiepileptics Corticosteroids Tetracycline L-tryptophan Anticholinergics.	Radiotherapy of the head and neck Pharyngitis Cervical web or rings Dental disease Oral candidiasis Tetanus Lead poisoning Rabies

The common causes of esophageal dysphagia can be divided into four categories.^{[5][6][7][8][9]}

Structural (Mechanical) disorders				Motor disorders		Esophageal tumors	Systemic diseases	Miscellaneous
Intrinsic compression		Extrinsic Compression		Primary	Secondary
Mucosal rings and webs Schatzki Plummer-Vinson Multiringed esophagus (eosinophilic esophagitis)	Strictures: PUD Caustic Pill-induced Radiation-induced	Vascular compression: Dysphagia lusoria (aberrant right subclavian artery) Dysphagia aortica (right-sided aorta) Cardio-megaly (enlarged left atrium)	Mediastinal masses: Lung cancer Lymphoma Lymphadenopathy Thyromegaly	Achalasia Diffuse esophageal spasm Hypertensive lower esophageal sphincter Ineffective esophageal motility disorder Nutcracker esophagus	Connective tissue diseases Scleroderma CREST syndrome Diabetes Chagas disease Paraneoplastic syndrome	Adenocarcinoma Squamous cell carcinoma Metastatic (breast or melanoma) Leiomyoma, lymphoma, or granular cell tumor	Scleroderma (multifactorial) Pemphigus/pemphigoid Lichen planus Crohn’s disease	Postsurgery (laryngeal, esophageal, or gastric cancers) Acute esophageal infections Esophageal diverticulae Foreign bodies

Less common causes of dysphagia include:

• Scleredema adultorum^[10][11]
• Post chemotherapy and radiation therapy^[12]
• Descending thoracic aorta aneurysm^[13]
• Hypertrophy of cricopharyngeal muscles^[14]

The causes of dysphagia based on the organ system are as follows:^[15][16]

Cardiovascular	Aberrant subclavian artery, amyloidosis, anomalous left pulmonary artery,aortic aneurysm, aortic arch anomalies, charge syndrome, double aortic arch, enlarged aorta, enlarged left atrium, hypokalemia, mitral valve stenosis, pericarditis, superior vena cava syndrome
Chemical / poisoning	Arizona bark scorpion poisoning, arsenic poisoning, botulism, cobra poisoning, fluoride poisoning, lead poisoning
Dermatologic	Behcet’s syndrome, dermatomyositis, polymyositis, Stevens-Johnson syndrome, systemic lupus erythematosus
Drug Side Effect	Antipsychotic medications, artemether and lumefantrin, atropine, botulinum toxin, bicalutamidechemotherapy, cyclosporine toxicity, cytarabine, dactinomycin, doxycycline, eletriptan, hydroxocobalaminhyoscyamine, ibandronate, ioxilan, ixabepilone, minocycline hydrochloride, nabumetone, neuroleptics, oxcarbazepine, pergolide, rimabotulinumtoxinb, riociguat, ropinirole, sargramostim, sertraline, scarlet fever, tiagabine
Ear Nose Throat	Carcinoma of the vocal tract, cricopharyngeal spasm, eagle syndrome, epiglottitis, Impaired sensitivity in the larynx, laryngeal cancer, nasopharyngeal carcinoma, oral pharyngeal disorders, oral submucous fibrosis, palatine tonsil, pharyngeal pouch, pharyngitis, pharynx cancer, quinsy, retropharyngeal abscess, tonsillar cancer
Endocrine	Cushing’s syndrome, diabetic neuropathy, goiter, hyperthyroidism, hypokalemia, hypothyroidism, paraganglioma, Riedel thyroiditis, subacute granulomatous thyroiditis, thymoma, thyroglossal cyst, thyroid cancer, anaplastic,thyrotoxicosis, vagal paraganglioma, De Quervain’s thyroiditis, solitary thyroid nodule
Environmental	No underlying causes
Gastroenterologic	Achalasia, adjustable gastric band, aerophagia, aspiration of foreign body, Barret’s syndrome,candida esophagitis, cascade stomach, caustic esophagitis, Crohn’s disease of the esophagus, diffuse esophageal spasm, diverticulum, eosinophilic esophagitis, eosinophilic gastroenteritis, esophageal atresia, esophageal cancer, esophageal cyst, esophageal diverticulum, esophageal leiomyoma, esophageal obstruction by a foreign body, esophageal pouch, esophageal spasm, esophageal stricture, esophageal web, esophageal moniliasis, esophageal sarcoidosis, esophageal trauma, esophagitis, esophagotracheal fistula, external esophageal compression, gastric cancer, gastric volvulus, gastritis, gastroesophageal reflux, gastrointestinal stromal tumor, gastroparesis, Gaucher disease, globus pharyngis, globus syndrome, hiatal hernia, hypertensive lower esophageal sphincter, infectious esophagitis, intramural pseudodiverticulosis, lymphocytic esophagitis, mitochondrial neurogastrointestinal encephalopathy syndrome, mucositis, myoneurogastrointestinal encephalopathy syndrome, nutcracker esophagus, odynophagia, peptic esophagitis, post surgery, peptic stricture, pharyngeal pouch, pill esophagitis, Plummer-Vinson syndrome, presbyphagia, pseudoachalasia, pyloric stenosis, radiation esophagitis, Schatzki ring, stomach cancer, upper oesophageal sphincter dysfunction, Wilson disease, zenker’s diverticulum
Genetic	Aberrant subclavian artery, achalasia-addisonian syndrome, achromatopsia, adrenoleukodystrophy, ataxia neuropathy spectrum,Behcet’s syndrome, chromosome 1p36 deletion syndrome, chromosome 22 ring, chromosome 22 trisomy mosaic, connective tissue disease, crisponi syndrome, Emanuel syndrome  , extreme spinal curvature, Gaucher disease,Huntington disease, lissencephaly, type 1, x-linked , muscular dystrophy, Duchenne and Becker type ,myotonic dystrophy, nemaline myopathy1, oculopharyngeal muscular dystrophy, Opitz-frias syndrome, pseudoadrenoleukodystrophy, spinal muscular atrophy type I, spinocerebellar ataxia 17  , spinocerebellar ataxia 22, spinocerebellar ataxia, autosomal recessive 1, Stuve-wiedemann dysplasia, vascular ring with right aortic arch, Wiedemann–Rautenstrauch syndrome, Wilson disease
Hematologic	Agranulocytosis, mononucleosis, Plummer-Vinson syndrome
Iatrogenic	No underlying causes
Infectious Disease	Abscess, angina tonsillaris, botulism, candida esophagitis, Chagas disease, cytomegalovirus, diphtheria, epiglottitis, gastritis, herpangina, herpes simplex virus, infectious esophagitis,laryngeal papillomatosis, lassa fever, Ludwig’s angina, lyme disease, lymph granulomatosis, Lymphadenopathy,Medication-induced esophagitis, mumps, neonatal tetanus  , oral candidiasis, paracoccidioidomycosis, Pharyngitis, polio, poliomyelitis, postpolio syndrome, quinsy, rabies, retropharyngeal abscess, snakebites, stomatitis, syphilis, tetanus, tetrodotoxin, tonsillar abscess, ulcer, Vincent’s angina
Musculoskeletal / Ortho	cytoplasmic body myopathy, Diffuse idiopathic skeletal hyperostosis, distal myopathy 2, elongated styloid process, extreme spinal curvature, inclusion body myositis, muscular dystrophy, Duchenne and Becker type, osteophytes, Pierre Robin’s sequence
Neurologic	10th cranial nerve disorder, amyotrophic lateral sclerosis, Arnold–Chiari malformation, ataxia neuropathy spectrum, autonomic nerve disorders, autonomic neuropathy, autosomal recessive spastic paraplegia, type 11, Avellis syndrome, Babinski–Nageotte syndrome, basal ganglia disease, basilar artery insufficiency syndrome, brain stem gliomas, brainstem stroke, brainstem tumors, pseudobulbar palsy, bulbar palsy, Canomad syndrome, carotid paraganglioma, central pontine myelinosis, central vagal nucleus lesion, central hypoglossal nerve paralysis, cerebellar Infarction, cerebellar stroke, cerebral palsy, cerebrovascular accident, congenital myasthenic syndrome, cervical osteophytes, dementia, diabetic neuropathy, dystonia, epileptic encephalopathy, early infantile, 1, fosmn syndrome, Guillain-Barre Syndrome, head trauma, Huntington disease, infantile striato-thalamic degeneration, lateral funiculus angina, lateral medullary syndrome, Lhermitte-cornil-quesnel syndrome, lissencephaly, type 1, x-linked, metabolic encephalopathies, microcephaly, mitochondrial neurogastrointestinal encephalopathy syndrome, motor neuron disease, multiple sclerosis, multiple system atrophy, muscular dystrophy, Duchenne and Becker type, myasthenia gravis, myoneurogastrointestinal encephalopathy syndrome, myopathy, myotonic dystrophy, neuroferritinopathy, neurosarcoidosis, osmotic demyelination syndrome, Pallidopyramidal syndrome, paraganglioma, paraneoplastic limbic encephalitis, Parkinson disease, peripheral neuropathy, peripheral tongue paralysis, polyradiculitis, pontocerebellar hypoplasia type 2a, primary lateral sclerosis, adult, primary motility disorders, Pseudobulbar paralysis,pseudodysphagia, secondary motility disorders, Shy-Drager syndrome, spastic paraplegia 11, autosomal recessive, spinal muscular atrophy type I, spinocerebellar ataxia 17 , spinocerebellar ataxia 22 , spinocerebellar ataxia, autosomal recessive 1, striatonigral degeneration infantile, stroke, syringobulbia, tardive dyskinesia, vagus nerve palsy, Wallenberg’s syndrome
Nutritional / Metabolic	Adrenoleukodystrophy, amyloidosis, Gaucher disease, hydroxocobalamin, hypokalemia, Plummer-Vinson syndrome, Wilson disease
Obstetric/Gynecologic	Leiomyoma
Oncologic	Acoustic neuroma, brain stem gliomas, brain stem tumors, bronchial carcinoma, carcinoma of the vocal tract, carotid body tumor, chordoma, esophageal cancer, gastric cancer, laryngeal cancer, laryngeal carcinoma, leiomyoma, lymphadenopathy, malignant lung cancer, malignant mesothelioma, nasopharyngeal carcinoma, neck cancer, odontoma, Oral cavity tumor, oropharyngeal cancer, palate cancer, paraganglioma, paraneoplastic limbic encephalitis, paraneoplastic syndrome, pharynx cancer, small cell lung cancer, stomach cancer, supraglottic laryngeal cancer, throat cancer, thyroid cancer, anaplastic, tongue cancer, tonsillar cancer, vagal paraganglioma
Opthalmologic	Achromatopsia, oculopharyngeal muscular dystrophy
Overdose / Toxicity	Alcoholism
Psychiatric	Anxiety disorders, dementia, frontotemporal dementia, functional disorders, global hystericus, rumination disorder, tardive dyskinesia
Pulmonary	Bronchial carcinoma, congenital bronchogenic cyst, epiglottitis, malignant lung cancer, malignant mesotheliomamediastinal mass, mediastinitis, Ondine’s curse, pharyngitis, pleuritis, sarcoidosis
Renal / Electrolyte	Hypomagnesemia primary, hypophosphatemia, systemic lupus erythematosus
Rheum / Immune / Allergy	Allergic swelling, amyloidosis, Behcet’s syndrome, Canomad syndrome, cervical osteophytes, CREST syndrome, dermatomyositis, diffuse systemic sclerosi, fibrosis, graft-versus-host disease, inclusion body myositis, muscular dystrophy, oculopharyngeal muscular dystrophy, osteophytes, paraneoplastic syndrome, polymyalgia rheumatica, polymyositis, rheumatoid arthritis, sarcoidosis, scleroderma, stomatitis, systemic lupus erythematosus, systemic sclerosis, trismus
Sexual	No underlying causes
Trauma	Head trauma
Urologic	No underlying causes
Dental	Vincent’s angina
Miscellaneous	Franek-bocker-kahlen syndrome, palatoplegia, tongue conditions, vascular abnormality

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Several diseases such as reflux esophagitis, esophageal carcinoma, systemic sclerosis, esophageal spasm, pseudoachalasia, stroke, esophageal candidiasis and Chagas disease can present with dysphagia, and hence must be differentiated from one another.

To review the differential diagnosis of dysphagia click here.

To review the differential diagnosis of dysphagia and weight loss click here.

To review the differential diagnosis of dysphagia and heartburn click here.

To review the differential diagnosis of dysphagia, weight loss and heartburn click here.

Dysphagia

Oropharyngeal dysphagia

Esophageal dysphagia

Solids only

Solids and Liquids

Solids only

Solids and Liquids

•Zenker’s diverticulum •Neoplasm •Webs

Neurogenic

Myogenic

Pain

•Achalasia •Scleroderma •DES

•Myasthenia gravis •Connective tissue disorder •Myotonic dystrophy

No

Yes

Heart burn

Barium swallow

Mental status

•Pill esophagitis •Caustic injury •Chemotherapy

Yes

No

Impaired

Normal

Non progressive

Progressive

Sac

Webs

Mass

Scleroderma

•Achalasia •DES

Stroke

•ALS •Parkinsonism

•Rings •Webs

•Strictures •Cancer

Zenker’s diverticulum

Plummer-Vinson syndrome

Carcinoma

Chest pain and manometry

Barium swallow

Weight loss

Increase LES pressure

Rings

Webs

Yes

No

Rapid

Slow

Achalasia

DES

Cancer

Strictures/GERD

Several diseases such as reflux esophagitis, esophageal carcinoma, systemic sclerosis, esophageal spasm, pseudoachalasia, stroke, esophageal candidiasis and Chagas disease can present with dysphagia, and hence must be differentiated from one another.^{[1][2][3][4][5][6][7][8][9][10][11]}

Disease	Signs and Symptoms								Barium esophagogram	Endoscopy	Other imaging and laboratory findings	Gold Standard
	Onset	Dysphagia			Weight loss	Heartburn	Other findings	Mental status
		Solids	Liquids	Type
Plummer-Vinson syndrome	Gradual	+	–	Non progressive	+/-	–	Glossitis Koilonychia	Normal	Thin projections on the anterior esophageal wall Multiple upperesophageal constrictions	Direct visualization of esophageal webs Superior to esophagogram	Videofluoroscopy shows mucosal and submucosal foldings	Triad of Iron deficiency anemia Esophageal webs Glossitis
Esophageal stricture	Gradual or sudden	+	–	Progressive	+/-	+/-	Odynophagia Cough Chest pain	Normal	Sacculations Fixed transverse folds Esophageal intramural pseudodiverticula	Mucosal edema Circumferential thickening in GERD Pale mucosa with white exudate in lymphocytic esophagitis Swelling and hemorrhagic congestion in causticingestion	Manometry may show dysmotility CT scan for staging malignant strictures	Barium esophagogram
Diffuse esophageal spasm	Sudden	+	+	Non progressive	+	+	Chest pain	Normal	Nonperistaltic and nonpropulsive contractions Corkscrew or rosary bead esophagus	Inconclusive	Manometry shows high-amplitude esophageal contractions CT scan may show hypertrophy of esophageal muscles	Manometry
Achalasia	Gradual	+	+	Non progressive	+/-	–	Regurgitation of undigested food Chest pain	Normal	“Bird’s beak” or “rat tail” appearance Dilated esophageal body Air fluid level (absent peristalsis) Absence of an intragastric air bubble	Dilated esophagus Residual food fragments Normal mucosa	Residual pressure of LES > 10 mmHg Incomplete relaxation of the LES Increased resting tone of LES Aperistalsis	History of dysphagia with positive endoscopy and manometry
Systemic sclerosis	Gradual	+	+	Progressive	+/-	+	Muscle and joint pain Raynaud’s phenomenon Skin changes	Normal	Dysmotility Patulous esophagus	Mucosal damage Peptic stricture (advanced cases)	Positive serology for Antinuclear antibodies Rheumatoid factor Creatine kinase ESR	Skin biopsy
Zenker’s diverticulum	Gradual	+	–		+/-	–	Food regurgitation Halitosis Cough Hoarseness	Normal	Thin projections on esophageal wall over Killian’s triangle	Outpouching of posterior pharyngeal wall Exclude the presence of SCC	CT & MRI shows out-pouching over the posterior esophagus in the Killian’s triangle	Barium esophagography
Esophageal carcinoma	Gradual	+	+	Progressive	+	+/-	Lymphadenopathy Cachexia	Normal	Irregular stricture Pre-stricture dilatation	Esophageal obstruction Staging of disease	CT and PET scan is an optional test for staging of the disease	Biopsy
Stroke (Cerebral hemorrhage)	Sudden	+	+	Progressive	+	+/-	Dysarthria Limb weakness Fatigue	Impaired	Pooling of contrast in the pharynx Aspiration of barium contrast into the airway	Reduced opening of upper esophageal sphincter Reduced larynx elevation	CT without contrast shows acute hemorrhage as a hyperattenuating clot	CT without contrast
Motor disorders (Myasthenia gravis)	Gradual	+	+	Progressive	+/-		Ptosis Diplopia Fatigue	Normal	Stasis in pharynx and pooling in pharyngeal recesses	Velopharyngeal insufficiency Delayed swallowing function	CT may show anterior mediastinal mass (thymoma) Positive tensilon test	Anti–acetylcholine receptor antibody test
GERD	Gradual or sudden onset	+	–	Progressive	+/-	+	Cough Hoarseness	Normal	Free acid reflux Esophagitis with scarring Strictures Barrett’s oesophagus	Erythema, erosions and ulceration Barrett’s esophagus	Esophageal manometry may show decreased tone of LES	24 hour esophageal pH monitoring
Esophageal web	Gradual	+	+/-	Progressive	–	+/-	Findings of the underlying cause such as iron deficiency anemia or bullous pemphigoid	Normal	Symmetrical narrowing of the esophagus	Smooth membrane not encircling the whole lumen	Videofluoroscopy shows mucosal and submucosal foldings	Barium esophagogram

• For the differential diagnosis based on dysphagia and weight loss click here.
• For the differential diagnosis based on dysphagia and heartburn click here.

References

1. ↑ Ferri, Fred (2015). Ferri’s clinical advisor 2015 : 5 books in 1. Philadelphia, PA: Elsevier/Mosby. ISBN 978-0323083751.
2. ↑ Boeckxstaens GE, Zaninotto G, Richter JE (2013). “Achalasia”. Lancet. doi:10.1016/S0140-6736(13)60651-0. PMID 23871090.CS1 maint: Multiple names: authors list (link)
3. ↑ Badillo R, Francis D (2014). “Diagnosis and treatment of gastroesophageal reflux disease”. World J Gastrointest Pharmacol Ther. 5 (3): 105–12. doi:10.4292/wjgpt.v5.i3.105. PMC 4133436. PMID 25133039.
4. ↑ Napier KJ, Scheerer M, Misra S (2014). “Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities”. World J Gastrointest Oncol. 6 (5): 112–20. doi:10.4251/wjgo.v6.i5.112. PMC 4021327. PMID 24834141.
5. ↑ Matsuura H (2017). “Diffuse Esophageal Spasm: Corkscrew Esophagus”. Am. J. Med. doi:10.1016/j.amjmed.2017.08.041. PMID 28943381.
6. ↑ Lassen JF, Jensen TM (1992). “[Corkscrew esophagus]”. Ugeskr. Laeg. (in Danish). 154 (5): 277–80. PMID 1736462.CS1 maint: Unrecognized language (link)
7. ↑ Ruigómez A, García Rodríguez LA, Wallander MA, Johansson S, Eklund S (2006). “Esophageal stricture: incidence, treatment patterns, and recurrence rate”. Am. J. Gastroenterol. 101 (12): 2685–92. doi:10.1111/j.1572-0241.2006.00828.x. PMID 17227515.
8. ↑ Shami VM (2014). “Endoscopic management of esophageal strictures”. Gastroenterol Hepatol (N Y). 10 (6): 389–91. PMC 4080876. PMID 25013392.
9. ↑ López Rodríguez MJ, Robledo Andrés P, Amarilla Jiménez A, Roncero Maíllo M, López Lafuente A, Arroyo Carrera I (2002). “Sideropenic dysphagia in an adolescent”. J. Pediatr. Gastroenterol. Nutr. 34 (1): 87–90. PMID 11753173.
10. ↑ Chisholm M (1974). “The association between webs, iron and post-cricoid carcinoma”. Postgrad Med J. 50 (582): 215–9. PMC 2495558. PMID 4449772.
11. ↑ Larsson LG, Sandström A, Westling P (1975). “Relationship of Plummer-Vinson disease to cancer of the upper alimentary tract in Sweden”. Cancer Res. 35 (11 Pt. 2): 3308–16. PMID 1192404.

Template:WH Template:WS