gastrointestinal disorders
Dysphagia
Evaluation of Dysphagia
History of present illnessbegins with duration of symptoms and acuity of onset. Patients should describe what substances cause difficulty and where they feel the disturbance is located. Specific concerns include whether patients have difficulty swallowing solids, liquids, or both; whether food comes out their nose; whether they drool or have food spill from their mouth; whether they have had food impaction; and whether they cough or choke while eating. Review of symptomsshould focus on symptoms suggestive of neuromuscular, gastrointestinal (GI), and connective tissue disorders and on the presence of complications. Important neuromuscular symptoms include weakness and easy fatigability, gait or balance disturbance, tremor, and difficulty speaking. Important GI symptoms include heartburn or other chest discomfort suggestive of reflux. Symptoms of connective tissue disorders include muscle and joint pain, Raynaud phenomenon, and skin changes (eg, rash, swelling, thickening). should ascertain known diseases that may cause dysphagia ( see Table: Some Causes of Oropharyngeal Dysphagia and see Table: Examination focuses on findings suggestive of neuromuscular, GI, and connective tissue disorders and on the presence of complications. General examination should evaluate nutritional status (including body weight). A complete neurologic examination is essential, with attention to any resting tremor, the cranial nerves (note the gag reflex may normally be absent; this absence is thus not a good marker of swallowing dysfunction), and muscle strength. Patients who describe easy fatigability should be observed performing a repetitive action (eg, blinking, counting aloud) for a rapid decrement in performance suggestive of Myasthenia Gravis . The patient’s gait should be observed, and balance should be tested. Skin is examined for rash and thickening or texture changes, particularly on the fingertips. Muscles are inspected for wasting and fasciculations and are palpated for tenderness. The neck is evaluated for thyromegaly or other mass. Any dysphagia is of concern, but certain findings are more urgent: Symptoms of complete obstruction (eg, drooling, inability to swallow anything) Dysphagia resulting in weight loss New focal neurologic deficit, particularly any objective weakness Recurrent aspiration pneumonia Dysphagia that occurs in conjunction with an acute neurologic event is likely the result of that event; new dysphagia in a patient with a stable, long-standing neurologic disorder may have another etiology. Dysphagia for solids alone suggests mechanical obstruction; however, a problem with both solids and liquids is nonspecific. Drooling and spilling food from the mouth while eating or nasal regurgitation suggests an oropharyngeal disorder. Regurgitation of a small amount of food on lateral compression of the neck is virtually diagnostic of pharyngeal diverticulum. Patients who complain of difficulty getting food to leave the mouth or of food sticking in the lower esophagus are usually correct about the condition’s location; the sensation of dysphagia in the upper esophagus is less specific. Many findings suggest specific disorders ( see Table: Some Helpful Findings in Dysphagia ) but are of varying sensitivity and specificity and thus do not rule in or out a given cause; however, they can guide testing. Upper endoscopy Barium swallow Patients with dysphagia should always have upper endoscopy, which is extremely important to rule out cancer. During endoscopy, esophageal biopsies should also be done to look for eosinophilic esophagitis. A barium swallow (with a solid bolus, usually a marshmallow or tablet) can be done if the patient is unable to undergo an upper endoscopy, or if upper endoscopy with biopsy does not identify a cause. If the barium swallow is negative and the upper endoscopy is normal, esophageal motility studies should be done. Other tests for specific causes are done as suggested by findings. Impedance Planimetry is a new technology that simultaneously measures the area across the inside of the esophagus and the pressure inside in the lumen. This procedure allows measurements of esophageal distensibility and may be helpful in the evaluation of patients with dysphagia. 