Dysphagia

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Dysphagia

Causes of dysphagia can be congenital, acquired, functional or iatrogenic and include:

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• Benign
• Peptic stricture
• Schatzki ring
• Webs
• Eosinophilic oesophagitis
• Caustic or radiation injury
• Medication-induced stricture
• Congenital abnormalities (e.g. vascular)
• Anastomotic strictures
• Benign tumours (e.g. leiomyoma)
• Malignant
• Carcinoma (squamous, adenocarcinoma), pseudoachalasia
• Extrinsic compression
• Motility disorders
• Achalasia
• Diffuse oesophageal spasm
• Scleroderma
• Non-specific motility disorders
• Functional disorders
• Patients with structural disorders typically have dysphagia to solids alone, whereas patients with motility disorders typically present with dysphagia to solids and liquids 2

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Oesophageal vs Oropharyngeal Dysphagia

• Dysphagia is defined as difficulty in swallowing solids, fluids or saliva 3,4
• A key decision is whether dysphagia is oropharyngeal and/or oesophageal. History can provide accurate assessment of the type of dysphagia in 80-85% of cases which can help guide further investigation and management 5
• Oropharyngeal dysphagia is often associated with other neurological deficits or clinical manifestations of an underlying disease 6
• Oesophageal dysphagia is often caused by localised neuromuscular disorders and obstructive lesions, including malignancy 6
Features of Oropharyngeal Dysphagia:

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• Difficulty initiating a swallow, repetitive swallowing
• Complaints of diet/fluid sticking in throat
• Nasal regurgitation
• Coughing, choking or frequent throat clearing during or after eating and drinking
• Drooling
• Dysarthria and diplopia (may accompany neurological conditions that cause oropharyngeal dysphagia). Other neurological deficits may point toward a specific neurological cause of dysphagia
• Recurrent pneumonia
• Weight loss, malnutrition or dehydration
Features of Oesophageal Dysphagia:

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• Feeling of food “sticking” in the throat or upper chest several seconds after swallowing
• Perceiving a point of obstruction below or behind the sternum
• Painful swallowing may indicate oesophagitis
• Associated heartburn, regurgitation or atypical symptoms of GORD including dyspnoea, chronic cough, hoarseness, throat clearing or sore throat
• Features that are concerning for malignancy include: 5,7
  • Short duration
  • Progression of symptoms
  • Dysphagia more for solids than liquids
  • Weight loss
  • Anaemia
Globus
• Globus is defined by the ROME III criteria as (must include all of the following and criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis): 8
  • Persistent or intermittent, non-painful sensation of a lump or foreign body in the throat
  • Occurrence of the sensation between meals
  • Absence of dysphagia or odynophagia
  • Absence of evidence that gastroesophageal reflux is the cause of the symptom
  • Absence of histopathology-based oesophageal motility disorders
• Globus without any other associated symptoms does not usually require further investigation 9

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Oesophagogastroduodenoscopy (OGD)

• Modality of choice to detect mucosal or structural abnormalities of the oesophagus and proximal stomach 10
• In the assessment of dysphagia, primary role of endoscopy is to exclude malignant cause
• One study suggests endoscopy with therapeutic intent was more cost-effective than an initial diagnostic barium swallow in patients with histories suggestive of benign strictures 11
• A large retrospective series of 1649 patients who had undergone endoscopy as the initial investigation for dysphagia, Varadarajulu et al. found that 50% had major pathology seen on endoscopy (e.g. oesophagitis 28%, stricture 21%), but the overall rate of malignancy was only 4% 12
• Advantages:
  • Able to assess mucosal lesions
  • Allows biopsies or cytology specimens to be taken
  • Allows therapeutic intervention at same setting (e.g. dilatation of strictures)
  • More sensitive than barium swallow study for diagnosing of mild reflux oesophagitis or other subtle forms of oesophagitis 13
• Limitations:
  • More expensive and invasive than barium swallow study, requires sedation
  • Inferior to barium studies for detection of lower oesophageal rings or strictures 13,14
  • Unable to evaluate oesophageal motility disorders 13

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Barium Swallow

• Fluoroscopic examination of the pharynx, oesophagus and proximal stomach. A comprehensive examination should be performed, including assessment of the pharyngeal and oesophageal phases of swallowing, assessment for gastro-oesophageal reflux and views of the proximal stomach. This provides functional/motility and anatomical information
• Examination is tailored to the patient's symptoms and usually involves a combination of single and double contrast studies 3,4
  • A double contrast study involves the oral administration of a gas-forming agent to provide maximal distension of the stomach and oesophagus, followed by the swallowing of high density barium. It is best for demonstrating mucosal abnormalities
  • A single contrast study involves the swallowing of low density barium and is best for detecting subtle strictures, schatzki rings and hiatus hernias
  • The use of solids coated in barium may also be used depending on the patient's symptoms
  • If there is a history suggestive of aspiration, non-ionic contrast medium should be used first because there are significant risks if barium is aspirated
• Evidence of gastro-oesophageal reflux and the rate of clearing of the refluxate from the oesophagus are also documented 15
• Symptoms of mid/distal oesophageal causes of dysphagia may be referred to the pharynx, but the reverse is rare. However, distal lesions may be associated with cricopharyngeal abnormalities (e.g. Zenker's diverticulum and distal stricture), therefore a comprehensive examination of all phases of swallowing should be performed 3,4
• Overall sensitivity of 75-90% for the diagnosis of oesophageal motility disorders in comparison to oesophageal manometry 13,16-18
• Advantages:
  • More sensitive than endoscopy for detection of lower oesophageal rings and strictures 13,14
  • Allows assessment of motility
  • Less expensive and invasive, and more readily available compared to endoscopy
• Limitations:
  • Lack of direct visualisation of mucosa and extra-luminal structures
  • Exposure to ionising radiation

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Computed Tomography (CT)

• Wide field of view can demonstrate cause of extrinsic strictures
• Can also allow tumour staging

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Endoscopic Ultrasound (EUS)

• Allows visualisation of the deeper wall layers and perioesophageal tissues
• Useful in assessment of submucosal lesions (e.g. leiomyoma), mediastinal disease and in locoregional staging of the oesophageal cancer 19
• Biopsies may also be taken during EUS
• Limitations:
  • Minimally invasive, requires sedation
  • Requires skilled operator

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Videofluoroscopic Swallow Study (VFSS)

• Previously considered the gold standard for evaluating oropharyngeal dysphagia. 5,20-22 More recently, the reported accuracy of FEES has been similar to VFSS 23
• Also known as a modified barium swallow 5
• Videofluoroscopy includes assessment of all phases of swallowing, with the patient swallowing barium or non-ionic contrast (barium contrast may cause mediastinitis if perforation is present so water-soluble contrast should be used when suspected). It can involve assessment with various consistencies of bolus, dependant on the patient's symptoms, including solids and liquids
• Can be used to assess the risk of aspiration pneumonia 5
• In many tertiary institutions, radiologists work closely with speech pathologists for the investigation of patients with oropharyngeal swallowing difficulties. Speech pathologists assess the swallow during the procedure

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Manometry

• Mildly invasive “gold standard” investigation for diagnosis of oesophageal motility disorders, especially achalasia 24-26
• Measures the amplitude, timing and configuration of oesophageal contractions and evaluates lower oesophageal sphincter (LES) function 24
• Routine use is not indicated because of the low specificity of the findings and low likelihood of detecting a clinically significant motility disorder 24
• Indications include: 24-27
  1. When abnormality is not identified on barium study or by endoscopy and correct diagnosis is essential and/or for which localisation of LES is important
  2. To establish or exclude the diagnosis of suspected cases of achalasia or diffuse oesophageal spasm
  3. To detect oesophageal motor abnormalities associated with systemic diseases (e.g. connective tissue diseases) if their detection would contribute to establishing a multisystem diagnosis or to other aspects of management
• Disadvantages: mildly invasive, patient discomfort and limited availability

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Radionuclide Oesophageal Transit Studies

• Simple, non-invasive method for assessing motility disorders and quantifying oesophageal emptying, and gastro-oesophageal reflux
• Patient swallows substances labelled with Tc-99m
• Provides information on bolus transit through the oesophagus that can complement manometric data
• Overall sensitivity of 68% for diagnosing oesophageal motility disorders using manometry as standard 16,28
• Useful for diagnosis of oesophageal involvement in systemic diseases, such as scleroderma or autonomic neuropathy

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Fibreoptic Endoscopic Evaluation of Swallowing (FEES)

• Insertion of a fibreoptic nasoendoscope to visualise pharyngeal and laryngeal anatomy and to assess secretion management and swallow function 5
• Nasoendoscopy can reveal structural causes of dysphagia 5
• VFSS has originally been considered the gold standard for the assessment of oropharyngeal dysphagia, but FEES has demonstrated similar accuracy in the limited number of available studies 23
• FEES only allows direct observation immediately before and after the swallow, while VFSS demonstrates the entire swallow 23

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