Diagnostic approach to Dysphagia

Dysphagia is the difficulty in swallowing, better defined as a sensation of sticking or obstruction of the passage of food through the oropharynx or oesophagus.

Aphagia signifies complete oesophageal obstruction,this is usually due to bolus impaction

Odynophagia is the painful swallowing

Phagophobia means fear of swallowing

Refusal to swallowis seen in hysteria, tetanus, rabies, pharyngeal paralysis and odynophagia.

Physiology of swallowing

• Voluntary phase - Oral bolus of food pushed to pharynx by the contraction of tongue
• Involuntary phase - Pharyngeal and oesophageal phase by deglutition reflex.

Anatomical types of dysphagia

• Oropharyngeal dysphagia
• Oesophageal dysphagia

Oropharyngeal disorder - results from neuromuscular dysfunction affecting the initiation of swallowing by the pharynx and upper oesophageal sphincter, also have nasal regurgitation and chocking due to tracheal aspiration.

Oesophageal disorder - results from structural or motility disorder producing the feel of food sticking after swallowing.

Etiological types of dysphagia 

Etiologically two groups of dysphagia is seen

• Mechanical or obstructive
• Motor dysphagia or paralytic dysphagia

1.Mechanical  causes of Dysphagia

• Luminal causes
• Intrinsic narrowing
• Extrinsic compression

2. Motor (Neuromuscular) causes of Dysphagia

• Difficulty in initiating swallowing reflex
• Disorders of pharyngeal and esophageal striated muscle
• Disorders of oesophageal smooth muscle

Etiological clues in dysphagia

• Dysphagia is a serious symptom unless it is associated with a transitory sore throat and so it has to be investigated thoroughly, especially to exclude upper gastrointestinal malignancy.
• Dysphagia occurring within  seconds of onset of swallowing suggests oropharyngeal cause.
• When swallowing is associated with a gurgling noise or neck bulge, think about pharyngeal pouch (Zenker's diverticulum).
• If the patient has dysphagia that is constant and painful, suspect malignant stricture.
• When there is difficulty in initiating swallowing, that is associated with cough or choking sensation, you should suspect an oropharyngeal cause of dysphagia.
• If the patient has a sensation of stopping or sticking of food bolus, after having initiated swallowing, suspect  oesophageal cause of dysphagia. It may be relieved by repeated swallowing or raising the arm over the head.
• Dysphagia for solid food only, suggests a mechanical obstruction. This, can be of the following:Intermittent, e.g. lower oesophageal ring Progressive, e.g. peptic stricture, carcinoma.
• Dysphagia for solid or liquid food suggests a neuromuscular disorder. This can be
• Intermittent dysphagia (diffuse oesophageal spasm)
• Progressive dysphagia (scleroderma involving lower 1 /3 of esophagus, achalasia cardia).