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Dysphagia, Odynophagia Heartburn, and Other Esophageal Symptoms

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Dysphagia, Odynophagia Heartburn, and Other Esophageal Symptoms DYSPHAGIA, ODYNOPHAGIA HEARTBURN, AND OTHER ESOPHAGEAL SYMPTOMS oel E. Richter DYSPHAGIA, 93 HEARTBURN (PYROSIS), 95 CHEST PAIN, 97 Mechanisms, 93 Symptom Complex, 95 Mechanisms, 98 Classification, 94 Mechanisms, 97 RESPIRATORY; EAR, NOSE, AND THROAT; AND CARDIAC SYMPTOMS, 99 ODYNOPHAGIA, 95 GLOBUS SENSATION, 97 Mechanisms, 97 ccasional esophageal complaints are common and usu- Mechanisms allyO are not harbingers of disease . A recent survey of healthy subjects in Olmsted County, Minnesota, found that 20%, Several mechanisms are responsible for dysphagia . The oro- regardless of gender or age, experienced heartburn at least pharyngeal swallowing mechanism and the primary and sec- weekly .' Surely every middle-aged American adult has had ondary peristaltic contractions of the esophageal body that one or more episodes of heartburn or chest pain and dyspha- follow usually transport solid and liquid boluses from the gia when swallowing dry or very cold foods or beverages . mouth to the stomach within 10 seconds (see Chapter 32, Frequent or persistent dysphagia, odynophagia, or heartburn section on coordinated esophageal motor activity) . If these immediately suggests an esophageal problem that necessi- orderly contractions fail to develop or progress, the accumu- tates investigation and treatment . Other, less specific symp- lated bolus of food distends the lumen and causes the dull toms of possible esophageal origin include globus sensation, discomfort that is dysphagia. Some people fail to stimulate chest pain, belching, hiccups, rumination, and extraesopha- proximal motor activity despite adequate distention of the geal complaints such as wheezing, coughing, sore throat, and organ.' Others, particularly the elderly, generate low-ampli- hoarseness, especially if other causes have been excluded . In tude primary or secondary peristaltic activity that is insuffi- particular, gastroesophageal reflux disease may manifest with cient for clearing the esophagus .6 A third group has primary these "atypical" complaints and should not be missed, be- or secondary motility disorders that grossly disturb the or- cause it is readily treatable (see Chapter 33, section on derly contractions of the esophageal body . Because these symptoms) . motor abnormalities may not be present with every swallow, dysphagia may wax and wane (see Chapter 32, sections on achalasia and spastic disorders of the esophagus) . DYSPHAGIA Mechanical narrowing of the esophageal lumen may in- terrupt the orderly passage of a food bolus despite adequate Dysphagia, from the Greek phagia (to eat) and dys (diffi- peristaltic contractions . Symptoms also vary with the degree culty, disordered), refers to the sensation of food being hin- of luminal obstruction, associated esophagitis, and type of dered in its passage from the mouth to the stomach . Most food ingested. Although minimally obstructing lesions cause patients say that food "sticks," "hangs up," or "stops" or that dysphagia only with large, poorly chewed solid boluses of they feel that the food "just won't go down right ." Occa- such foods as meat and dry bread, lesions that totally ob- sionally they complain of associated pain . Dysphagia always struct the esophageal lumen are symptomatic for both solids indicates malfunction of some type in the esophagus, al- and liquids. Gastroesophageal ref ux disease may produce though associated psychiatric disorders can amplify this dysphagia by multiple mechanisms, including the syndrome symptom . of "nonobstructive" dysphagia7 (see Chapter 33, section on Dysphagia is a common symptom, present in 12% of symptoms) . Difficulty swallowing in this situation usually patients admitted to an acute care hospital and in over results from intermittent acid-induced motility disturbances 50% of those in a chronic care facility .2 An accurate, de- sometimes associated with mild to moderate esophageal in- tailed history suggests its etiology and enables the phy- flammation. Finally, abnormal sensory perception within the sician to correctly define the cause in 80% to 85% of esophagus may lead to dysphagia. Because some normal patients.3 ° 4 subjects experience the sensation of dysphagia when the 93 ~A71Ef4TS WWiTH SYMPTOMS AND SIGNS distal esophagus is distended by a balloon, as well as by sodes during a meal indicate a concomitant tracheobronchial other intraluminal stimuli, an aberration in visceral percep- aspiration. Pain is infrequent ; dysphagia predominates . tion could explain dysphagia in patients who have no defina- Other symptoms are less frequent and may be progres- ble cause.' This mechanism also may apply to the amplifica- sive, constant, or intermittent . Swallowing associated with a tion of symptoms in patients with spastic motility disorders, gurgling noise may suggest the presence of Zenker diverticu- among whom the prevalence of psychiatric disorders is lum (see Chapter 31, section on diverticula; also Chapter 20, high.9 section on diverticula of esophagus) . Recurrent bouts of pul- monary infection may reflect spillover of food into the tra- Classification chea from inadequate laryngeal protection . Hoarseness may result from recurrent laryngeal nerve dysfunction or intrinsic muscular disease, both of which cause ineffective vocal cord Dysphagia is readily classified into two distinct types : oro- movement . Weakness of the soft palate or pharyngeal con- pharyngeal and esophageal (Table 6-1) . The former is strictors causes dysarthria and nasal speech as well as pha- caused by abnormalities that affect the fine-tuned neuromus- ryngonasal regurgitation . Finally, unexplained weight loss cular mechanism of the pharynx and upper esophageal may be the only clue to a swallowing disorder ; patients sphincter (UES) ; the latter stems from one of a variety of avoid eating because of the difficulties encountered . disorders that affect the esophageal body . Oropharyngeal Dysphagia Esophageal Dysphagia Neuromuscular diseases that affect the hypopharynx and up- Various motility disorders or mechanical obstructing lesions per esophagus produce a distinctive type of dysphagia . The can cause esophageal dysphagia . Most patients complain of patient is often unable to initiate swallowing and repeatedly difficulty "transporting" food down the esophagus, noting has to attempt to swallow . A food bolus cannot be propelled the sensation of food "hanging up" somewhere behind the successfully from the hypopharyngeal area through the UES sternum . If this symptom is localized to the lower part of the into the esophageal body. The resulting symptom is oropha- sternum, the lesion probably is in the distal esophagus ; how- ryngeal, or transfer, dysphagia . The patient is aware that the ever, dysphagia frequently may be referred to the neck or bolus has not left the oropharynx and specifically locates the substernal notch from that site in some patients . site of symptoms to the region of the cervical esophagus . To understand the syndrome of esophageal dysphagia, the Dysphagia within 1 second of swallowing is suggestive of answers to three questions are crucial : 10 (1) What type of an oropharyngeal abnormality .' In this situation, a liquid food causes symptoms? (2) Is the dysphagia intermittent or bolus may enter the trachea or the nose rather than the progressive? and (3) Does the patient have heartburn? On esophagus . Some patients describe recurrent bolus impaction the basis of these answers, it often is possible to distinguish that requires manual dislodgment . In severe cases, saliva the cause of dysphagia as either a mechanical or a neuro- cannot be swallowed, and the patient drools . Coughing epi- muscular defect and to accurately postulate the cause (Fig . 6-1). Patients who report dysphagia with both solids and liq- Table 6-1 1 Common Causes of Dysphagia uids probably have an esophageal motility disorder . When food impaction develops, it frequently can be relieved by OROPHARYNGEAL ESOPHAGEAL various maneuvers, including repeated swallowing, raising Neuromuscular Mechanical Obstruction the arms over the head, throwing the shoulders back, and Cerebrovascular accident Benign strictures using the Valsalva maneuver. In addition to dysphagia, most Parkinson disease Webs and rings (Schatzki) patients with achalasia complain of bland regurgitation of Brainstem tumors Neoplasm undigested food, especially at night, and of weight loss. In Multiple sclerosis Diverticula Amyotrophic lateral sclerosis Vascular anomalies contrast, patients with spastic motility disorders commonly Peripheral neuropathies (i.e ., Aberrant subclavian artery (dys- complain of chest pain and sensitivity to either hot or cold poliomyelitis) phagia lusoria) liquids . Patients with scleroderma of the esophagus usually Mechanical Obstruction Enlarged aorta (dysphagia aortica) have Raynaud's phenomenon and severe heartburn . In these Retropharyngeal abscess Motility Disorders Zenker diverticulum Achalasia patients, mild complaints of dysphagia can be caused by Cricopharyngeal bar Spastic motility disorders either a motility disturbance or esophageal inflammation, but Cervical osteophyte Scleroderma severe dysphagia nearly always signals the presence of a Thyromegaly Chagas disease peptic stricture (see Chapter 32, sections on achalasia, spas- Skeletal Muscle Disorders Miscellaneous tic disorders of esophagus, and systemic diseases of esopha- Polymyositis Miscellaneous Muscular dystrophies Diabetes gus). Myotonic dystrophy Alcoholism In patients who report dysphagia only after swallowing Oculopharyngeal dystrophy
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