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Swallowing problems

Medicine > Gastrointestinal

Differential Diagnosis Schema 🧠

Oropharyngeal Dysphagia

  • Neurological disorders: Stroke, Parkinson’s disease, multiple sclerosis, myasthenia gravis, leading to impaired coordination of swallowing muscles.
  • Muscular disorders: Conditions like myopathies or muscular dystrophies affecting the muscles involved in swallowing.
  • Obstructive causes: Pharyngeal or esophageal tumors, tonsillar hypertrophy, or Zenker’s diverticulum causing mechanical obstruction.
  • Infectious causes: Pharyngitis, abscesses, or opportunistic infections in immunocompromised patients causing pain or obstruction.
  • Iatrogenic causes: Post-surgical complications, radiation therapy, or intubation leading to scarring or dysfunction.

Esophageal Dysphagia

  • Mechanical obstruction: Esophageal carcinoma, benign strictures, Schatzki rings, or eosinophilic esophagitis causing narrowing of the esophagus.
  • Motility disorders: Achalasia, diffuse esophageal spasm, or scleroderma leading to impaired peristalsis.
  • Gastroesophageal reflux disease (GERD): Chronic acid exposure leading to inflammation, stricture formation, or Barrett’s esophagus.
  • Foreign bodies: Ingestion of large or sharp objects causing acute obstruction or perforation.
  • Infectious esophagitis: Candida, herpes simplex virus, or cytomegalovirus infections, particularly in immunocompromised patients.

Key Points in History 🥼

Onset and Progression

  • Acute vs. chronic: Sudden onset suggests foreign body, infection, or stroke; gradual onset is more typical of progressive conditions like cancer or achalasia.
  • Intermittent vs. continuous: Intermittent symptoms may suggest motility disorders, while continuous symptoms are more likely due to mechanical obstruction.
  • Progression: Worsening symptoms over time may indicate a growing tumor or worsening stricture.
  • Context of onset: Onset during eating may suggest a foreign body or food bolus impaction, while gradual onset might be related to progressive diseases.

Associated Symptoms

  • Painful swallowing (odynophagia): Suggests infectious esophagitis, severe GERD, or malignancy.
  • Regurgitation: May indicate achalasia, Zenker’s diverticulum, or esophageal stricture.
  • Weight loss: Concerning for malignancy or severe motility disorders causing chronic malnutrition.
  • Coughing or choking: Suggests aspiration, which may occur in oropharyngeal dysphagia or in the context of neuromuscular disorders.
  • Heartburn: Common in GERD, which can lead to esophageal stricture or Barrett’s esophagus.
  • Hoarseness: May indicate laryngeal involvement, often associated with GERD or malignancy.
  • Neurological symptoms: Weakness, facial droop, or other signs of neurological impairment may suggest a stroke or neuromuscular disorder.

Background

  • Past medical history: Stroke, neurological disorders, head and neck cancer, GERD, or history of esophageal surgery.
  • Medication history: Medications that can affect swallowing (e.g., anticholinergics, bisphosphonates, certain antibiotics) or cause dry mouth.
  • Family history: Inherited conditions such as muscular dystrophies, achalasia, or hereditary cancer syndromes.
  • Social history: Smoking, alcohol use, and occupational exposure to irritants that increase the risk of malignancy.
  • Surgical history: Previous surgeries to the neck, chest, or upper gastrointestinal tract that could contribute to dysphagia.
  • Dietary habits: Patterns of food intake, any recent changes, and any specific foods that exacerbate symptoms.

Possible Investigations 🌡️

Imaging Studies

  • Barium swallow: Useful for assessing structural abnormalities, such as strictures, diverticula, or motility disorders.
  • Endoscopy (OGD): Direct visualization of the esophagus and stomach to identify tumors, strictures, or inflammatory conditions. Biopsies can be taken during this procedure.
  • CT or MRI scan: Indicated if malignancy is suspected or to assess for extrinsic compression from surrounding structures.
  • Videofluoroscopic swallow study (VFSS): Dynamic study used to assess oropharyngeal dysphagia, particularly in patients with neurological conditions.
  • Manometry: Esophageal motility study useful in diagnosing disorders like achalasia or diffuse esophageal spasm.
  • Chest X-ray: Can identify mediastinal masses, aspiration pneumonia, or other lung pathology secondary to dysphagia.

Laboratory Tests

  • Full blood count (FBC): To check for anemia, which may be secondary to chronic blood loss (e.g., esophageal cancer) or malnutrition.
  • C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): Markers of inflammation, which may be elevated in infections or inflammatory conditions like esophagitis.
  • Thyroid function tests: To rule out thyroid enlargement or dysfunction as a cause of extrinsic esophageal compression.
  • Autoimmune screening: Tests for conditions like myasthenia gravis (e.g., acetylcholine receptor antibodies) or systemic sclerosis (e.g., anti-centromere antibodies) if suspected.
  • Nutritional assessment: Serum albumin, prealbumin, and other markers to assess nutritional status, especially in chronic dysphagia.
  • Microbiological cultures: In cases of suspected infectious esophagitis, particularly in immunocompromised patients.

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Gastrointestinal