Chapter 038. Dysphagia (Part 5)

Diseases of the striated muscle often also involve the cervical part of the esophagus, in addition to affecting the oropharyngeal muscles. Clinical manifestations of the cervical esophageal involvement are usually overshadowed by those of the oropharyngeal dysphagia.Diseases of the smooth-muscle segment involve the thoracic part of the esophagus and the LES. Dysphagia occurs when the peristaltic contractions are weak or absent or when the contractions are nonperistaltic. Loss of peristalsis may be associated with failure of LES relaxation. Weakness of contractile power occurs due to muscle weakness, as in scleroderma or impaired cholinergic effect. Nonperistaltic contractions and failure of...
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Chapter 038. Dysphagia (Part 5) Chapter 038. Dysphagia (Part 5) Diseases of the striated muscle often also involve the cervical part of theesophagus, in addition to affecting the oropharyngeal muscles. Clinicalmanifestations of the cervical esophageal involvement are usually overshadowedby those of the oropharyngeal dysphagia. Diseases of the smooth-muscle segment involve the thoracic part of theesophagus and the LES. Dysphagia occurs when the peristaltic contractions areweak or absent or when the contractions are nonperistaltic. Loss of peristalsis maybe associated with failure of LES relaxation. Weakness of contractile poweroccurs due to muscle weakness, as in scleroderma or impaired cholinergic effect.Nonperistaltic contractions and failure of LES relaxation occur due to impairedinhibitory innervation. In diffuse esophageal spasm (DES), inhibitory innervationonly to the esophageal body is impaired, whereas in achalasia inhibitoryinnervation to both the esophageal body and LES is impaired. Dysphagia due toesophageal muscle weakness is often associated with symptoms ofgastroesophageal reflux disease (GERD). Dysphagia due to loss of the inhibitoryinnervation is typically not associated with GERD but may be associated withchest pain. The causes of esophageal motor dysphagia are also listed in Table 38-2;they include scleroderma of the esophagus, achalasia, DES, and other motordisorders. Approach to the Patient: Dysphagia Figure 38-1 shows an algorithm of approach to a patient with dysphagia. Approach to the patient with dysphagia. ENT, ear, nose, and throat;VFSS, videofluoroscopic swallowing study. HISTORY The history can provide a presumptive diagnosis in >80% of patients. Thesite of dysphagia described by the patient helps to determine the site of esophagealobstruction; the lesion is at or below the perceived location of dysphagia. Associated symptoms provide important diagnostic clues. Nasalregurgitation and tracheobronchial aspiration with swallowing are hallmarks ofpharyngeal paralysis or a tracheoesophageal fistula. Tracheobronchial aspirationunrelated to swallowing may be due to achalasia, Zenkers diverticulum, orgastroesophageal reflux. Association of laryngeal symptoms and dysphagia occurs in variousneuromuscular disorders. The presence of hoarseness may be an importantdiagnostic clue. When hoarseness precedes dysphagia, the primary lesion isusually in the larynx; hoarseness following dysphagia may suggest involvement ofthe recurrent laryngeal nerve by extension of esophageal carcinoma. Sometimeshoarseness may be due to laryngitis secondary to gastroesophageal reflux. Hiccupsmay rarely occur with a lesion in the distal portion of the esophagus. Unilateralwheezing with dysphagia may indicate a mediastinal mass involving theesophagus and a large bronchus. The type of food causing dysphagia provides useful information. Difficultyonly with solids implies mechanical dysphagia with a lumen that is not severelynarrowed. In advanced obstruction, dysphagia occurs with liquids as well assolids. In contrast, motor dysphagia due to achalasia and DES is equally affectedby solids and liquids from the very onset. Patients with scleroderma havedysphagia to solids that is unrelated to posture and to liquids while recumbent butnot upright. When peptic stricture develops in patients with scleroderma,dysphagia becomes more persistent. The duration and course of dysphagia are helpful in diagnosis. Transientdysphagia may be due to an inflammatory process. Progressive dysphagia lasting afew weeks to a few months is suggestive of carcinoma of the esophagus. Episodicdysphagia to solids lasting several years indicates a benign disease characteristicof a lower esophageal ring. Severe weight loss that is out of proportion to the degree of dysphagia ishighly suggestive of carcinoma.