General Approach to Patients presenting with Dysphagia

Difficulty in initiating a swallow, misdirectional food causing coughing, choking, or nasal regurgitation YES (+ Localized to chest or throat) Oropharyngeal dysphagia Neuromuscular findings YES NO Oropharyngeal motor dysphagia Oropharyngeal mechanical dysphagia Fauci et al:17th Ed. Harrison’s Principles of Internal Medicine.p.240,2008

YES NO Oropharyngeal motor dysphagia Oropharyngeal mechanical dysphagia Mental Status ENT Evaluation IMPAIRED NORMAL Videofluoroscopic swallowing study Oral phase abnormalities Pharyngeal phase abnormalities Fauci et al:17th Ed. Harrison’s Principles of Internal Medicine.p.240,2008

Difficulty in initiating a swallow, misdirectional food causing coughing, choking, or nasal regurgitation NO (+ Localized to chest or throat) Esophageal dysphagia Dysphagia to solids or liquids SOLIDS AND LIQUIDS SOLIDS ONLY Fauci et al:17th Ed. Harrison’s Principles of Internal Medicine.p.240,2008

YES NO SOLIDS AND LIQUIDS SOLIDS ONLY Esophagial Motor dysphagia Esophageal mechanical dysphagia Barium swallow Esophageal motility esophagoscopy Esophagoscopy Barium swallow + Prominent heartburn Episodic or progressive YES NO EPISODIC PROGRESSIVE Scleroderma Achalasia Lower esophageal ring Carcinoma Fauci et al:17th Ed. Harrison’s Principles of Internal Medicine.p.240,2008

Differential Diagnosis ESOPHAGEAL DYSPHAGIA

ESOPHAGEAL DYSPHAGIA ESOPHAGEAL MECHANICAL DYSPHAGIA WALL DEFECTS INTRINSIC NARROWING EXTRINSIC COMPRESSION Congenital Tracheoesophageal Fistula Inflammatory esophagitis (Viral, Bacterial, Fungal, Caustic/Thermal/Chemical injury) Webs and Rings (Esophageal, Schatzki’s ring, GVHD) Benign Strictures (Peptic, Caustic, Pill-induced, Crohn’s disease) Tumors (Benign, Malignant) Vascular compression Posterior mediastinal mass Postvagotomy hematoma and fibrosis Fauci et al:17th Ed. Harrison’s Principles of Internal Medicine.p.238-239,2008

ESOPHAGEAL DYSPHAGIA ESOPHAGEAL MOTOR DYSPHAGIA DISORDERS OF CERVICAL ESOPHAGUS DISORDERS OF THORACIC ESOPHAGUS Oropharyngeal motor disorders Diseases of cerebral cortex and brainstem (dementia, meningitis, cerebrovascular accident) Cranial Nerve Deficits (V, VII, IX, X, XII) Neuromuscular (myasthenia gravis, botulinum toxin) Muscle disorder (myositis, oculopharyngeal myopathy) Diseases of smooth muscle or excitatory nerves: a.) weak muscle contraction (scleroderma, myotonic dystrophy), b.) enhanced muscle contraction (hypertensive peristalsis) Disorders of inhibitory innervation (diffuse esophageal spasm, achalasia, contractile lower esophageal ring) Fauci et al:17th Ed. Harrison’s Principles of Internal Medicine.p.238-239,2008