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Dysphagia, Emergency Medicine

Basics

Description

- Esophageal (transport) dysphagia: - Failure of normal transit through the esophagus - Retrosternal sticking sensation seconds after swallowing - Nocturnal regurgitation/aspiration - Drooling or regurgitation of undigested food and liquid (characteristic of esophageal obstruction) - Motility disorder vs. mechanical obstruction

- Functional dysphagia: - Diagnosis of exclusion - Full workup without evidence of mechanical or neuromuscular pathology - Symptoms >12 wk

- Pain pattern: - Overall poor ability to localize pain with dysphagia, although oropharyngeal source is better - Somatic nerve fibers in the upper esophagus; better pain localization - Visceral pain from the lower esophagus is poorly localized and may be difficult to distinguish from that of acute coronary syndrome.

- Pediatric dysphagia: - Common causes in infants/newborns include prematurity, congenital malformations, neuromuscular disease, infection (e.g., candidiasis), inflammation - Always consider foreign body aspiration in a child presenting with dysphagia - Other common causes in children include caustic ingestions, infections, and neurologic disorders including sequelae from head injury - Acquired tracheoesophageal fistula in children may result from ingestions (disk battery, caustic ingestions) or prior surgery - Other life-threatening causes of dysphagia include epiglottitis, retropharyngeal abscess, CNS infection, botulism, esophageal perforation, diphtheria

- CXR: - Achalasia food dilating the esophagus may be seen as widened mediastinum, air-fluid level in posterior mediastinum - Aspiration pneumonitis - Extrinsic compressing mass

- Soft tissue lateral neck radiograph - Modified barium swallow (with solid bolus) or videofluoroscopy: - Defines esophageal anatomy - Assesses function - Do not perform if endoscopy anticipated

- Oropharyngeal: - Infectious: - Botulism - CNS infections - Mucositis - Lyme disease

- Mechanical: - Congenital - Malignancy - Pharyngeal pouch

- Inflammatory: - Eosinophilic esophagitis - Pill esophagitis

- Extrinsic: - Cardiovascular abnormalities (vascular rings, thoracic aneurysm, left atrial enlargement, aberrant subclavian artery) - Cervical osteophytes - Mediastinal mass

  • Difficulty swallowing
  • Can be neuromuscular or mechanical

Etiology

  • Oropharyngeal (transfer) dysphagia:Difficulty transferring from the mouth to the proximal esophagus (difficulty initiating a swallow)Easier to swallow solids vs. liquidsImmediate, within seconds of swallowingAssociated with nasal or oral regurgitation, coughing, or chokingUsually a neuromuscular disorder resulting in bulbar muscle weakness or impaired coordination
  • Esophageal (transport) dysphagia:Failure of normal transit through the esophagusRetrosternal sticking sensation seconds after swallowingNocturnal regurgitation/aspirationDrooling or regurgitation of undigested food and liquid (characteristic of esophageal obstruction)Motility disorder vs. mechanical obstruction
  • Functional dysphagia:Diagnosis of exclusionFull workup without evidence of mechanical or neuromuscular pathologySymptoms >12 wk
  • Odynophagia:Pain with swallowingSeparate, but often related, entity
  • Pain pattern:Overall poor ability to localize pain with dysphagia, although oropharyngeal source is betterSomatic nerve fibers in the upper esophagus; better pain localizationVisceral pain from the lower esophagus is poorly localized and may be difficult to distinguish from that of acute coronary syndrome.
  • Pediatric dysphagia:Common causes in infants/newborns include prematurity, congenital malformations, neuromuscular disease, infection (e.g., candidiasis), inflammationAlways consider foreign body aspiration in a child presenting with dysphagiaOther common causes in children include caustic ingestions, infections, and neurologic disorders including sequelae from head injuryAcquired tracheoesophageal fistula in children may result from ingestions (disk battery, caustic ingestions) or prior surgeryOther life-threatening causes of dysphagia include epiglottitis, retropharyngeal abscess, CNS infection, botulism, esophageal perforation, diphtheria

Diagnosis

Signs and Symptoms

  • Difficulty initiating swallowing
  • Sensation of food stuck after swallowing
  • Cough/choke after eating
  • Impairment of gag reflex and ability to clear bolus
  • Voice change/dysphonia
  • Drooling
  • Dysarthria
  • Chest pain

History

  • Is there difficulty swallowing solids, liquids, or both?Solids and liquids suggest a neuromuscular disorder.Solids only or progression from solids to liquids suggests a mechanical abnormality.
  • How long after swallowing do symptoms occur?Immediate onset of symptoms suggests oropharyngeal causeDelay (seconds after swallowing) suggests esophageal cause
  • Are symptoms intermittent or progressive?Intermittent symptoms suggest rings or webs.Progressive symptoms suggest peptic or malignant strictures.Motility disorders can be intermittent or progressive.
  • How long have the symptoms been present?Acute onset is more concerning for acutely life-threatening etiologyFood impaction is the most common cause of acute-onset dysphagiaMalignancy may also progressive relatively quickly
  • Are there other associated symptoms?e.g., nasal regurgitation, choking, heartburn, weight loss

Physical Exam

  • Often unremarkable
  • Oropharyngeal inspection
  • Pulmonary and cardiac auscultation
  • Neurologic exam with emphasis on cranial nerves (esp. V, VII, IX, X, XII)

Essential Workup

  • Adequate airway evaluation
  • Thorough neurologic exam

Diagnosis Tests & Interpretation

EKG:

  • Consider cardiac etiology for chest discomfort

Lab

No specific studies are indicated.

Imaging

  • CXR:Achalasia food dilating the esophagus may be seen as widened mediastinum, air-fluid level in posterior mediastinumAspiration pneumonitisExtrinsic compressing mass
  • Soft tissue lateral neck radiograph
  • Modified barium swallow (with solid bolus) or videofluoroscopy:Defines esophageal anatomyAssesses functionDo not perform if endoscopy anticipated
  • CT/MRI of the head:Indicated for new-onset neuromuscular dysphagia

Diagnostic Procedures/Surgery

  • Often performed in the outpatient setting
  • Upper endoscopy:Indicated to relieve obstruction and inspect the esophageal anatomyBiopsy possible if indicated
  • Esophageal manometry
  • Fiberoptic nasopharyngeal laryngoscopy

Differential Diagnosis

  • Oropharyngeal:Infectious:BotulismCNS infectionsMucositisLyme diseaseMechanical:CongenitalMalignancyPharyngeal pouchMedications:Antibiotics (especially doxycycline)Aspirin and NSAIDsBisphosphonatesFerrous sulfatePotassium chlorideQuinidineNeuromuscular:Amyotrophic lateral sclerosisCerebrovascular accidentGuillain-Barr © syndromeCranial nerve palsyHuntington choreaMultiple sclerosisMyasthenia gravisParkinson diseaseTraumatic brain injuryPsychological/behavioral
  • Esophageal:Mechanical:DiverticulaEsophageal websForeign bodyNeoplasmPeptic esophageal stricturePostsurgical (laryngeal, spinal)Radiation injurySchatzki ringMotor:AchalasiaChagasCushing syndromeDiffuse esophageal spasmHyperthyroidism/hypothyroidismNutcracker esophagusSclerodermaVitamin B12 deficiencyInflammatory:Eosinophilic esophagitisPill esophagitisExtrinsic:Cardiovascular abnormalities (vascular rings, thoracic aneurysm, left atrial enlargement, aberrant subclavian artery)Cervical osteophytesMediastinal mass

Treatment

Pre-Hospital

  • Vigilant airway attention
  • Position of comfort with suction available

Initial Stabilization/Therapy

  • Vigilant airway attention
  • Position of comfort with suction available
  • NPO
  • 0.9% NS 500 mL (peds: 20 mL/kg) IV fluid bolus for significant dehydration
  • Evaluate for life-threatening causes of dysphagia includingRetropharyngeal hematoma/abscessEpiglottitisForeign bodyUpper airway obstructionCardiovascular causes (thoracic aortic aneurysm)

Ed Treatment/Procedures

  • Nitroglycerin for esophageal spasm
  • Glucagon for impacted foreign body
  • Treat complications:Airway obstructionAspiration, pneumonia, lung abscessDehydration, malnutrition
  • Endoscopy
  • Dietary modifications:Thickened liquids for neuromuscular disorderThin liquids for mechanical disorders

Medication

First Line

  • Glucagon for food impaction: 1 mg IV followed by 2nd dose of 1 mg after 5 min if there is no improvement in symptoms (0.02-0.03 mg/kg in children, not to exceed 0.5 mg):Success rates vary from 12-50%, which may not be better than spontaneous passage.

Second Line

Calcium channel blockers and nitrates may be used in motility disorders (e.g., achalasia and nutcracker esophagus)

Follow-Up

Disposition

Admission Criteria

  • Esophageal obstruction persists despite treatment
  • Compromised fluid or nutrition status
  • Inability to protect airway
  • Unable to tolerate own secretions

Discharge Criteria

  • Well-hydrated patient
  • Urgent neurology, otolaryngology, or gastroenterology referral arranged for further evaluation and treatment

Issues for Referral

Next day follow-up with PCP or ENT/GI

Follow-Up Recommendations

  • Clear liquid diet prior to ENT follow-up
  • Return if SOB, chest pain, or unable to tolerate own secretions.

Pearls and Pitfalls

  • Consider foreign-body aspiration in children presenting with dysphagia.
  • Dysphagia is a common presentation in stroke.
  • Consider in patients with recurrent pneumonia.
  • Assess for life-threatening causes of dysphagia before deferring definitive diagnosis to outpatient setting.

Additional Reading

  • Fass R. Evaluation of dysphagia in adults. Cited from UpToDate.com. Accessed February 22, 2013.
  • Furnival RA, Woodward GA. Pain-dysphagia. In: Fleisher GR, Ludwig S, Henretig FM, eds. Textbook of Pediatric Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
  • Seamens CS, Brywczynski. Esophageal disorders. In: Harwood Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
  • Smith Hammond CA, Goldstein LB. Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines. Chest. 2006;129:154S-168S.
  • Yal §in Åž, Ciftci AO, Karnak I, et al. Management of acquired tracheoesophageal fistula with various clinical presentations. J Pediatr Surg. 2011; 46(10):1887-1892.

See Also (Topic, Algorithm, Electronic Media Element)

Stroke

Codes

ICD9

  • 787.20 Dysphagia, unspecified
  • 787.22 Dysphagia, oropharyngeal phase
  • 787.24 Dysphagia, pharyngoesophageal phase
  • 787.29 Other dysphagia
  • 787.21 Dysphagia, oral phase
  • 787.23 Dysphagia, pharyngeal phase
  • 787.2 Dysphagia

ICD10

  • R13.10 Dysphagia, unspecified
  • R13.12 Dysphagia, oropharyngeal phase
  • R13.14 Dysphagia, pharyngoesophageal phase
  • R13.19 Other dysphagia
  • R13.11 Dysphagia, oral phase
  • R13.13 Dysphagia, pharyngeal phase
  • R13.1 Dysphagia

SNOMED

  • 40739000 Dysphagia (disorder)
  • 71457002 Oropharyngeal dysphagia (disorder)
  • 40890009 Esophageal dysphagia (disorder)
  • 249485007 Food sticks on swallowing (disorder)
  • 429975007 Oral phase dysphagia