1. General Approach to Patients presenting with Dysphagia

2. 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

3. 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

4. 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

5. 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

6. Differential Diagnosis
ESOPHAGEAL DYSPHAGIA

7. 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 ,2008

8. 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 ,2008