#395 Dysphagia with Dr. Diana Snyder

May 15, 2023 | By Elena Gibson

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There might be a lot to swallow, but you will master an initial approach to dysphagia in this episode. Review the types of dysphagia, common etiologies, initial evaluations and treatment plans. We are joined by Dr. Diana Snyder @DianaSnyderMD (Mayo Clinic)

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Show Segments

• Intro & Picks of the Week
• Case 
• Dysphagia definitions
• Oropharyngeal vs esophageal dysphagia 
• Associated symptoms and alarm signs 
• Outro

Dysphagia Pearls

1. To distinguish globus sensation from dysphagia, ask about how the symptom changes while swallowing. Globus will typically improve while swallowing and dysphagia will not change or worsen. 
2. Oropharyngeal dysphagia includes any etiology of dysphagia resulting from pathology above the upper esophageal sphincter. 
3. Symptoms of oropharyngeal dysphagia include coughing, nasal regurgitation of liquids, and halitosis.
4. Esophageal dysphagia includes any etiology of dysphagia resulting from pathology below the upper esophageal sphincter.
5. A modified barium swallow study is useful in the evaluation of patients with symptoms of oropharyngeal dysphagia. 
6. Studies for motility disorders including manometry should be considered in patients with dysphagia to liquids.
7. Eosinophilic esophagitis is an increasingly prevalent etiology of dysphagia. 
8. The diagnosis of eosinophilic esophagitis is made with 1)clinical symptoms including dysphagia and 2) histologic evidence of >15 eosinophils per high powered field. 

Dysphagia Notes

Dysphagia itself is the subjective sensation that something isn’t moving from oropharynx to the stomach. Odynophagia is pain with swallowing. Globus is when the patient feels like something is sitting in the throat or there is a “lump in the throat”. Dr. Snyder typically distinguishes between dysphagia and globus sensation by asking how the symptom changes when swallowing. Globus typically improves with swallowing.

Oropharyngeal vs. Esophageal Dysphagia 

Dysphagia is typically separated into two broad categories: oropharyngeal and esophageal (Liu 2018). 

• Oropharyngeal Dysphagia: due to pathology above the upper esophageal sphincter (mouth, throat, pharynx) 
• Esophageal Dysphagia:  due to pathology below the upper esophageal sphincter 

Oropharyngeal dysphagia has numerous categories for potential etiologies including: 

• Structural ENT structural problems: cricopharyngeal hypertrophy or bar, Zenker’s diverticulum
• Neurologic conditions: CVA, Parkinsons, Myasthenia Gravis, Myopathies 
• Medication Induced: anticholinergics  

Esophageal dysphagia has multiple “buckets” of potential etiologies including:

• inflammatory conditions (erosive esophagitis, eosinophilic esophagitis, reflux esophagitis, pill esophagitis)
• primary motility disorders (most common achalasia)
• secondary motility disorders (scleroderma, opioids)
• structural abnormalities (stricture, rings, malignancy) 

Initial History

Symptoms associated with oropharyngeal dysphagia include nasal regurgitation of liquids, coughing and choking with the initiation of swallowing, and bad breath (Liu 2018). Dr. Snyder asks patients to point to where they are having a difficult time swallowing or food/liquids are getting stuck. However, the location above the sternal notch or below the sternal notch does not always correlate correctly with oropharyngeal vs. esophageal dysphagia respectively due to the extensive crossing of neural pathways in the esophagus.  

It is important to determine the types of items a patient is having dysphagia with. First, identify if a patient is having difficulty with solids and liquids. If dysphagia to solid foods is present, ask additional questions about the types of solids. Is dysphagia occurring with more difficult solid foods like dry bread, meat and rice? Softer solids like oatmeal? 

• Dysphagia to solids progresses to include liquids: increased concern  for structural esophageal dysphagia and malignancy
• Simultaneous dysphagia to solids and liquids: motility etiologies 

Associated Signs & Symptoms

Alarm symptoms to ask about include weight loss, bleeding, emesis, and aspiration pneumonia. Associated symptoms to ask about to work towards determining the etiology of dysphagia include reflux symptoms as erosive reflux and peptic strictures are a common cause of dysphagia. Consider rumination if patients describe an effortless regurgitation of intake. For the evaluation of possible eosinophilic esophagitis (EoE) ask about compensatory mechanisms such as slow eating, increased liquid intake, and chewing slowly. Atopic conditions including asthma, eczema, and allergic rhinitis are also associated with an increased risk of EoE. 

For oropharyngeal dysphagia, it is important to evaluate for smoking and tobacco use history as this significantly increases the risk of oropharyngeal malignancy. 

Evaluation

Who should get an EGD? And who should get a modified barium study? Almost any patient with progressive dysphagia warrants an upper endoscopy as dysphagia alone is an alarm symptom warranting endoscopic evaluation (ASGE Committee 2013). For patients with oropharyngeal dysphagia- a speech consult and modified barium swallow study should be completed. Consider ENT referral for patients with oropharyngeal dysphagia to evaluate the oropharynx with laryngoscopy. 

Imaging 

For typical solid food dysphagia, imaging with an esophagram or modified barium swallow study (MBSS) is not required and proceeding directly to endoscopy is recommended. However, Dr. Snyder describes how additional imaging is often used by specialists to provide guidance prior to endoscopy for conditions such as complex esophageal stricture. 

A modified barium swallow study is a video fluoroscopic swallow study that should be utilized for patients where there is a concern for oropharyngeal dysphagia (ie symptoms=coughing, choking, liquid regurgitation through nose, halitosis) (Liu 2018). 

Dr. Snyder recommends a low threshold to order an esophagram as the study is easy to perform, inexpensive and not harmful to patients. An esophagram is a good starting point, particularly for patients where an endoscopic procedure carries increased risk. For patients with achalasia there are specific barium protocols used to asses illness severity 

Diagnosis & Management 

Eosinophilic esophagitis 

EoE is one of the most prevalent etiologies of dysphagia. EoE is a clinical histologic diagnosis requiring 1) dysphagia and 2) endoscopic findings: >15 eosinophils per high powered field on biopsy of lower/mid or upper esophagus, furrows, rings, edema, exudates and strictures.  The prevalence of EoE has increased in recent years to an estimated 1 in 1000 to 2000 (Dellon 2018). The prevalence of achalasia for comparison is 1 in 100,000. Roughly 40 to 50% of patients are histologic responders to proton pump inhibitors. EoE is a Th2 mediated immune reaction so there are factors such as eotaxin 3 that the PPI directly targets. So, PPIs are not only treating reflux overlap but also treating EoE directly (Muir 2021). It is reasonable to trial a PPI fo if patients present with symptoms of reflux esophagitis, but if there is a high level of concern for EoE a PPI can lead to 40% histologic response and the correct diagnosis could be missed on initial endoscopic evaluation. 

Treatment options for EoE include PPI, topical steroids and less commonly systemic immunosuppressants. Follow up for EoE should include evaluation of clinical and histologic changes. When treatment for EoE is initiated or changed, it is necessary to define histologic response with a goal of <15 eosinophils per HPF on histology (Hirano 2020). 

Non Cardiac Chest Pain

Could this be esophageal spasm? Typically these patients need an upper endoscopy with esophageal biopsies as it could be an atypical presentation of EoE. In addition, pH reflux testing is often completed as acid reflux alone can present with an atypical spasm pain. Far less common is a true motility disorder and distal esophageal spasm. This can be identified on high resolution esophageal manometry studies. However, this is very rare with <1% of all manometry studies identified distal esophageal spasm. 

Links

1. The Lost Kitchen (show)

Goal

Listeners will develop an approach to the initial diagnosis and management of dysphagia 

Learning objectives

After listening to this episode listeners will…

1. Distinguish oropharyngeal dysphagia from esophageal dysphagia 
2. Define globus sensation and potential etiologies 
3. Characterize signs and symptoms associated with dysphagia 
4. Identify an algorithm to the initial evaluation and management of dysphagia 

Disclosures

Dr. Snyder reports no relevant financial disclosures.The Curbsiders report no relevant financial disclosures. 

Citation

Gibson EG, Snyder D, Williams PN, Watto MF. “#395 Dysphagia with Diana Snyder”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast #395 Final publishing date May 15, 2023.