Dysphagia resident survival guide: Difference between revisions
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{{WikiDoc CMG}}; {{AE}}{{MRV}} | {{WikiDoc CMG}}; {{AE}}{{MRV}}<br> | ||
{{SK}} Approach to dysphagia, Dysphagia algorithm, Dysphagia workup, Dysphagia management, Dysphagia diagnostic approach | |||
'''For the WikiDoc page for this topic, click [[Dysphagia|here]]''' | |||
==Overview== | ==Overview== | ||
Dysphagia is defined as "difficulty swallowing." It is a sensation that suggests difficulty in the passage of [[Solid|solids]] or [[Liquid|liquids]] from the [[mouth]] to the [[stomach]]. According to the International Classification of Diseases (ICD-10) which is endorsed by the [[World Health Organization|WHO]], dysphagia is a [[symptom]] rather than a [[disease]]. Dysphagia can result from propulsive failure, motility disorders, structural disorders, [[Intrinsic factor|intrinsic]] or extrinsic compression of the [[oropharynx]] or [[esophagus]]. Dysphagia is distinguished from similar symptoms including [[odynophagia]], which is defined as painful [[swallowing]], and [[Globus pharyngis|globus]], which is the sensation of a [[lump]] in the [[throat]]. The [[endoscopy]] for [[esophageal dysphagia]] should be performed when the patient presented with [[symptoms]] of difficulty [[swallowing]], painful [[swallowing]], and [[Aspiration (medicine)|aspiration]]. This is the standard test performed when the [[patient]] has a risk of developing [[pneumonia]] and diagnosing [[swallowing]] difficulties. Videofluoroscopic swallowing study is performed for [[Pharynx|oropharyngeal]] dysphagia. It provides information about delay in initiation of pharyngeal [[swallowing]], [[Nasopharynx|nasopharyngeal]] regurgitation, residue of ingested food within the [[Pharynx|pharyngeal]] cavity after [[swallowing]], and [[Aspiration (medicine)|aspiration]] of ingested food. The cornerstone of any dysphagia evaluation is a detailed history and a thorough review of [[symptoms]] that can differentiate [[esophageal]] from [[Pharynx|oropharyngeal]] dysphagia and help predict the specific [[etiology]] of dysphagia with an [[accuracy]] of approximately 80% confirmed by specific testing. How a patient describes his or her difficulty and its timing, associated [[symptoms]], and other characterizations may specifically denote the [[anatomic]] level of [[swallowing]] dysfunction. | |||
==Causes== | ==Causes== | ||
===Life Threatening Causes=== | ===Life Threatening Causes=== | ||
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. There are no known life-threatening causes of [[dysphagia]]. | Life-threatening causes include [[conditions]] that may result in death or permanent disability within 24 hours if left untreated. There are no known life-threatening causes of [[dysphagia]]. | ||
===Common Causes=== | ===Common Causes=== | ||
Depending upon the type of dysphagia, the causes can be categorized into two subsections:<ref name="MalageladaBazzoli2015">{{cite journal|last1=Malagelada|first1=Juan-R.|last2=Bazzoli|first2=Franco|last3=Boeckxstaens|first3=Guy|last4=De Looze|first4=Danny|last5=Fried|first5=Michael|last6=Kahrilas|first6=Peter|last7=Lindberg|first7=Greger|last8=Malfertheiner|first8=Peter|last9=Salis|first9=Graciela|last10=Sharma|first10=Prateek|last11=Sifrim|first11=Daniel|last12=Vakil|first12=Nimish|last13=Le Mair|first13=Anton|title=World Gastroenterology Organisation Global Guidelines|journal=Journal of Clinical Gastroenterology|volume=49|issue=5|year=2015|pages=370–378|issn=0192-0790|doi=10.1097/MCG.0000000000000307}}</ref><ref name="CookKahrilas1999">{{cite journal|last1=Cook|first1=Ian J.|last2=Kahrilas|first2=Peter J.|title=AGA technical review on management of oropharyngeal dysphagia|journal=Gastroenterology|volume=116|issue=2|year=1999|pages=455–478|issn=00165085|doi=10.1016/S0016-5085(99)70144-7}}</ref><ref name="PhilpottGarg2017">{{cite journal|last1=Philpott|first1=Hamish|last2=Garg|first2=Mayur|last3=Tomic|first3=Dunya|last4=Balasubramanian|first4=Smrithya|last5=Sweis|first5=Rami|title=Dysphagia: Thinking outside the box|journal=World Journal of Gastroenterology|volume=23|issue=38|year=2017|pages=6942–6951|issn=1007-9327|doi=10.3748/wjg.v23.i38.6942}}</ref><ref name="EspitalierFanous2018">{{cite journal|last1=Espitalier|first1=F.|last2=Fanous|first2=A.|last3=Aviv|first3=J.|last4=Bassiouny|first4=S.|last5=Desuter|first5=G.|last6=Nerurkar|first6=N.|last7=Postma|first7=G.|last8=Crevier-Buchman|first8=L.|title=International consensus (ICON) on assessment of oropharyngeal dysphagia|journal=European Annals of Otorhinolaryngology, Head and Neck Diseases|volume=135|issue=1|year=2018|pages=S17–S21|issn=18797296|doi=10.1016/j.anorl.2017.12.009}}</ref><ref name="Abdel JalilKatzka2015">{{cite journal|last1=Abdel Jalil|first1=Ala' A.|last2=Katzka|first2=David A.|last3=Castell|first3=Donald O.|title=Approach to the Patient with Dysphagia|journal=The American Journal of Medicine|volume=128|issue=10|year=2015|pages=1138.e17–1138.e23|issn=00029343|doi=10.1016/j.amjmed.2015.04.026}}</ref><ref name="LiuAndrews2018">{{cite journal|last1=Liu|first1=Louis W C|last2=Andrews|first2=Christopher N|last3=Armstrong|first3=David|last4=Diamant|first4=Nicholas|last5=Jaffer|first5=Nasir|last6=Lazarescu|first6=Adriana|last7=Li|first7=Marilyn|last8=Martino|first8=Rosemary|last9=Paterson|first9=William|last10=Leontiadis|first10=Grigorios I|last11=Tse|first11=Frances|title=Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia|journal=Journal of the Canadian Association of Gastroenterology|volume=1|issue=1|year=2018|pages=5–19|issn=2515-2084|doi=10.1093/jcag/gwx008}}</ref> | Depending upon the type of dysphagia, the [[causes]] can be categorized into two subsections:<ref name="MalageladaBazzoli2015">{{cite journal|last1=Malagelada|first1=Juan-R.|last2=Bazzoli|first2=Franco|last3=Boeckxstaens|first3=Guy|last4=De Looze|first4=Danny|last5=Fried|first5=Michael|last6=Kahrilas|first6=Peter|last7=Lindberg|first7=Greger|last8=Malfertheiner|first8=Peter|last9=Salis|first9=Graciela|last10=Sharma|first10=Prateek|last11=Sifrim|first11=Daniel|last12=Vakil|first12=Nimish|last13=Le Mair|first13=Anton|title=World Gastroenterology Organisation Global Guidelines|journal=Journal of Clinical Gastroenterology|volume=49|issue=5|year=2015|pages=370–378|issn=0192-0790|doi=10.1097/MCG.0000000000000307}}</ref><ref name="CookKahrilas1999">{{cite journal|last1=Cook|first1=Ian J.|last2=Kahrilas|first2=Peter J.|title=AGA technical review on management of oropharyngeal dysphagia|journal=Gastroenterology|volume=116|issue=2|year=1999|pages=455–478|issn=00165085|doi=10.1016/S0016-5085(99)70144-7}}</ref><ref name="PhilpottGarg2017">{{cite journal|last1=Philpott|first1=Hamish|last2=Garg|first2=Mayur|last3=Tomic|first3=Dunya|last4=Balasubramanian|first4=Smrithya|last5=Sweis|first5=Rami|title=Dysphagia: Thinking outside the box|journal=World Journal of Gastroenterology|volume=23|issue=38|year=2017|pages=6942–6951|issn=1007-9327|doi=10.3748/wjg.v23.i38.6942}}</ref><ref name="EspitalierFanous2018">{{cite journal|last1=Espitalier|first1=F.|last2=Fanous|first2=A.|last3=Aviv|first3=J.|last4=Bassiouny|first4=S.|last5=Desuter|first5=G.|last6=Nerurkar|first6=N.|last7=Postma|first7=G.|last8=Crevier-Buchman|first8=L.|title=International consensus (ICON) on assessment of oropharyngeal dysphagia|journal=European Annals of Otorhinolaryngology, Head and Neck Diseases|volume=135|issue=1|year=2018|pages=S17–S21|issn=18797296|doi=10.1016/j.anorl.2017.12.009}}</ref><ref name="Abdel JalilKatzka2015">{{cite journal|last1=Abdel Jalil|first1=Ala' A.|last2=Katzka|first2=David A.|last3=Castell|first3=Donald O.|title=Approach to the Patient with Dysphagia|journal=The American Journal of Medicine|volume=128|issue=10|year=2015|pages=1138.e17–1138.e23|issn=00029343|doi=10.1016/j.amjmed.2015.04.026}}</ref><ref name="LiuAndrews2018">{{cite journal|last1=Liu|first1=Louis W C|last2=Andrews|first2=Christopher N|last3=Armstrong|first3=David|last4=Diamant|first4=Nicholas|last5=Jaffer|first5=Nasir|last6=Lazarescu|first6=Adriana|last7=Li|first7=Marilyn|last8=Martino|first8=Rosemary|last9=Paterson|first9=William|last10=Leontiadis|first10=Grigorios I|last11=Tse|first11=Frances|title=Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia|journal=Journal of the Canadian Association of Gastroenterology|volume=1|issue=1|year=2018|pages=5–19|issn=2515-2084|doi=10.1093/jcag/gwx008}}</ref> | ||
====Common Causes of Oropharyngeal Dysphagia==== | ====Common [[Causes]] of Oropharyngeal Dysphagia==== | ||
{| class="wikitable" | {| class="wikitable" | ||
! colspan="4" |Common causes of oropharyngeal dysphagia | ! colspan="4" align="center" style="background: #4479BA; color: #FFFFFF |Common causes of oropharyngeal dysphagia | ||
|- | |- | ||
| align="center" style="background: #4479BA; color: #FFFFFF |Neuromuscular disorders | |||
| align="center" style="background: #4479BA; color: #FFFFFF |Mechanical and obstructive causes | |||
| align="center" style="background: #4479BA; color: #FFFFFF |Medication side effects | |||
| align="center" style="background: #4479BA; color: #FFFFFF |Others | |||
|- | |- | ||
| | | | ||
| Line 56: | Line 61: | ||
* [[Thyromegaly]] | * [[Thyromegaly]] | ||
* [[Lymphadenopathy]] | * [[Lymphadenopathy]] | ||
* Cervical rings or cervical webs | *[[Tracheal rings|Cervical rings]] or cervical webs | ||
* [[Strictures]] | * [[Strictures]] | ||
* [[Oropharyngeal cancer|Oropharyngeal tumors]] | * [[Oropharyngeal cancer|Oropharyngeal tumors]] | ||
* [[Head and neck cancer|Head and neck tumors]] | * [[Head and neck cancer|Head and neck tumors]] | ||
* Surgical and/or radiotherapeutic interventions<br>on [[Head and neck cancer|head and neck tumors]] | *[[Surgical]] and/or radiotherapeutic interventions <br>on [[Head and neck cancer|head and neck tumors]] | ||
* [[Retropharyngeal abscess]] | * [[Retropharyngeal abscess]] | ||
*[[Congenital Abnormalities|Congenital]] ([[cleft palate]], [[Diverticular|diverticula]] | *[[Congenital Abnormalities|Congenital]] ([[cleft palate]], [[Diverticular|diverticula]], etc.) | ||
|Medications that reduce salivary flow: | |[[Medications]] that reduce [[Saliva|salivary]] flow: | ||
*[[Anticholinergics]] | *[[Anticholinergics]] | ||
| Line 71: | Line 76: | ||
*[[Antihistamines]] | *[[Antihistamines]] | ||
*[[Antiarrhythmics]] | *[[Antiarrhythmics]] | ||
*[[Anticonvulsant|Antiepileptics]] | |||
*[[Antipsychotics]] | *[[Antipsychotics]] | ||
*[[Mexiletine]] | *[[Mexiletine]] | ||
| Line 85: | Line 91: | ||
*[[Sjögren's syndrome|Sjogren's syndrome]] | *[[Sjögren's syndrome|Sjogren's syndrome]] | ||
*[[Pharyngitis]] | *[[Pharyngitis]] | ||
*Dental disease | *[[Dental disease]] | ||
*[[Mucositis]] ([[Oral candidiasis]],<br>[[herpes simplex|Herpetic lesions]], [[Cytomegalovirus]]) | *[[Mucositis]] ([[Oral candidiasis]],<br>[[herpes simplex|Herpetic lesions]], [[Cytomegalovirus]]) | ||
* | *Caustic [[ingestion]]/ injury | ||
*[[Diphtheria]] | *[[Diphtheria]] | ||
*[[Tetanus]] | *[[Tetanus]] | ||
| Line 96: | Line 102: | ||
====Common Causes of Esophageal Dysphagia==== | ====Common Causes of Esophageal Dysphagia==== | ||
The common causes of esophageal dysphagia can be divided into four categories.<ref name="pmid24513804">{{cite journal| author=Xiao Y, Kahrilas PJ, Nicodème F, Lin Z, Roman S, Pandolfino JE| title=Lack of correlation between HRM metrics and symptoms during the manometric protocol. | journal=Am J Gastroenterol | year= 2014 | volume= 109 | issue= 4 | pages= 521-6 | pmid=24513804 | doi=10.1038/ajg.2014.13 | pmc=4120962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24513804 }} </ref><ref name="pmid21480936">{{cite journal| author=Enestvedt BK, Williams JL, Sonnenberg A| title=Epidemiology and practice patterns of achalasia in a large multi-centre database. | journal=Aliment Pharmacol Ther | year= 2011 | volume= 33 | issue= 11 | pages= 1209-14 | pmid=21480936 | doi=10.1111/j.1365-2036.2011.04655.x | pmc=3857989 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21480936 }} </ref><ref name="pmid1398223">{{cite journal| author=Howard PJ, Maher L, Pryde A, Cameron EW, Heading RC| title=Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh. | journal=Gut | year= 1992 | volume= 33 | issue= 8 | pages= 1011-5 | pmid=1398223 | doi= | pmc=1379432 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1398223 }} </ref><ref name="pmid25965233">{{cite journal| author=Pandolfino JE, Gawron AJ| title=Achalasia: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 18 | pages= 1841-52 | pmid=25965233 | doi=10.1001/jama.2015.2996 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25965233 }} </ref><ref name="pmid12850684">{{cite journal| author=Gockel I, Lord RV, Bremner CG, Crookes PF, Hamrah P, DeMeester TR| title=The hypertensive lower esophageal sphincter: a motility disorder with manometric features of outflow obstruction. | journal=J Gastrointest Surg | year= 2003 | volume= 7 | issue= 5 | pages= 692-700 | pmid=12850684 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12850684 }} </ref> | The common [[causes]] of esophageal dysphagia can be divided into four categories.<ref name="pmid24513804">{{cite journal| author=Xiao Y, Kahrilas PJ, Nicodème F, Lin Z, Roman S, Pandolfino JE| title=Lack of correlation between HRM metrics and symptoms during the manometric protocol. | journal=Am J Gastroenterol | year= 2014 | volume= 109 | issue= 4 | pages= 521-6 | pmid=24513804 | doi=10.1038/ajg.2014.13 | pmc=4120962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24513804 }} </ref><ref name="pmid21480936">{{cite journal| author=Enestvedt BK, Williams JL, Sonnenberg A| title=Epidemiology and practice patterns of achalasia in a large multi-centre database. | journal=Aliment Pharmacol Ther | year= 2011 | volume= 33 | issue= 11 | pages= 1209-14 | pmid=21480936 | doi=10.1111/j.1365-2036.2011.04655.x | pmc=3857989 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21480936 }} </ref><ref name="pmid1398223">{{cite journal| author=Howard PJ, Maher L, Pryde A, Cameron EW, Heading RC| title=Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh. | journal=Gut | year= 1992 | volume= 33 | issue= 8 | pages= 1011-5 | pmid=1398223 | doi= | pmc=1379432 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1398223 }} </ref><ref name="pmid25965233">{{cite journal| author=Pandolfino JE, Gawron AJ| title=Achalasia: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 18 | pages= 1841-52 | pmid=25965233 | doi=10.1001/jama.2015.2996 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25965233 }} </ref><ref name="pmid12850684">{{cite journal| author=Gockel I, Lord RV, Bremner CG, Crookes PF, Hamrah P, DeMeester TR| title=The hypertensive lower esophageal sphincter: a motility disorder with manometric features of outflow obstruction. | journal=J Gastrointest Surg | year= 2003 | volume= 7 | issue= 5 | pages= 692-700 | pmid=12850684 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12850684 }} </ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
! colspan="4" |Structural (Mechanical) disorders | ! colspan="4" align="center" style="background: #4479BA; color: #FFFFFF |Structural (Mechanical) disorders | ||
! colspan="2" |Motor disorders | ! colspan="2" align="center" style="background: #4479BA; color: #FFFFFF |Motor disorders | ||
! rowspan="2" |Esophageal tumors | ! rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF |Esophageal tumors | ||
! rowspan="2" |Systemic diseases | ! rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF |Systemic diseases | ||
! rowspan="2" |Miscellaneous | ! rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF |Miscellaneous | ||
|- | |- | ||
! colspan="2" |'''Intrinsic compression''' | ! colspan="2" align="center" style="background: #4479BA; color: #FFFFFF |'''Intrinsic compression''' | ||
! colspan="2" |'''Extrinsic Compression''' | ! colspan="2" align="center" style="background: #4479BA; color: #FFFFFF |'''Extrinsic Compression''' | ||
| align="center" style="background: #4479BA; color: #FFFFFF |'''Primary''' | |||
| align="center" style="background: #4479BA; color: #FFFFFF |'''Secondary''' | |||
|- | |- | ||
|'''Mucosal rings and webs''' | |'''Mucosal rings and webs''' | ||
| Line 113: | Line 119: | ||
* [[Plummer-Vinson syndrome|Plummer-Vinson]] | * [[Plummer-Vinson syndrome|Plummer-Vinson]] | ||
* Multiringed esophagus [[Eosinophilic esophagitis|(eosinophilic esophagitis]]) | * Multiringed esophagus [[Eosinophilic esophagitis|(eosinophilic esophagitis]]) | ||
|'''Strictures:''' | |'''[[Strictures]]:''' | ||
* [[Peptic ulcer|PUD]] | * [[Peptic ulcer|PUD]] | ||
* [[Caustic]] | * [[Caustic]] | ||
* Pill-induced | * Pill-induced | ||
* Radiation-induced | *[[Radiation]]-induced | ||
|'''Vascular compression:''' | |'''[[Vascular]] compression:''' | ||
* Dysphagia lusoria ([[Aberrant subclavian artery |aberrant right subclavian artery]]) | * Dysphagia lusoria ([[Aberrant subclavian artery|aberrant right subclavian artery]]) | ||
* Dysphagia aortica (enlarged [[aorta]]) | * Dysphagia aortica (enlarged [[aorta]]) | ||
* [[Cardiomegaly | * [[Cardiomegaly]] (enlarged [[left atrium]]) | ||
| | | | ||
* '''Mediastinal masses:''' | * '''Mediastinal masses:''' | ||
| Line 133: | Line 139: | ||
* [[Achalasia]] | * [[Achalasia]] | ||
* [[Diffuse esophageal spasm]] | * [[Diffuse esophageal spasm]] | ||
* Hypertensive lower esophageal sphincter | * Hypertensive [[lower esophageal sphincter]] | ||
* Ineffective esophageal motility disorder | * Ineffective [[esophageal motility disorder]] | ||
* [[Nutcracker esophagus]] | * [[Nutcracker esophagus]] | ||
| | | | ||
| Line 160: | Line 166: | ||
* Postsurgery ([[Laryngeal cancer|laryngeal]], [[Esophageal cancer|esophageal]], or [[Stomach cancer|gastric cancers]]) | * Postsurgery ([[Laryngeal cancer|laryngeal]], [[Esophageal cancer|esophageal]], or [[Stomach cancer|gastric cancers]]) | ||
* Infection [[esophagitis]] ([[Candidiasis|Candida]], [[Cytomegalovirus]]) | * Infection [[esophagitis]] ([[Candidiasis|Candida]], [[Cytomegalovirus]]) | ||
* Esophageal diverticula | *[[Esophageal diverticulum|Esophageal diverticula]] | ||
*[[Foreign bodies]] | *[[Foreign bodies]] | ||
|} | |} | ||
===Less Common Causes=== | ===Less Common Causes=== | ||
Less common causes of [[dysphagia]] include: | Less common [[causes]] of [[dysphagia]] include: | ||
* Scleredema adultorum<ref name="pmid29280826">{{cite journal| author=Chatterjee S, Hedman BJ, Kirby DF| title=An Unusual Cause of Dysphagia. | journal=J Clin Rheumatol | year= 2017 | volume= | issue= | pages= | pmid=29280826 | doi=10.1097/RHU.0000000000000666 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29280826 }} </ref><ref name="pmid7064968">{{cite journal| author=Wright RA, Bernie H| title=Scleredema adultorum of Buschke with upper esophageal involvement. | journal=Am J Gastroenterol | year= 1982 | volume= 77 | issue= 1 | pages= 9-11 | pmid=7064968 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7064968 }} </ref> | * Scleredema adultorum<ref name="pmid29280826">{{cite journal| author=Chatterjee S, Hedman BJ, Kirby DF| title=An Unusual Cause of Dysphagia. | journal=J Clin Rheumatol | year= 2017 | volume= | issue= | pages= | pmid=29280826 | doi=10.1097/RHU.0000000000000666 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29280826 }} </ref><ref name="pmid7064968">{{cite journal| author=Wright RA, Bernie H| title=Scleredema adultorum of Buschke with upper esophageal involvement. | journal=Am J Gastroenterol | year= 1982 | volume= 77 | issue= 1 | pages= 9-11 | pmid=7064968 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7064968 }} </ref> | ||
* Post [[chemotherapy]] and [[radiation therapy]]<ref name="pmid11920484">{{cite journal| author=Nguyen NP, Sallah S, Karlsson U, Antoine JE| title=Combined chemotherapy and radiation therapy for head and neck malignancies: quality of life issues. | journal=Cancer | year= 2002 | volume= 94 | issue= 4 | pages= 1131-41 | pmid=11920484 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11920484 }} </ref> | * Post [[chemotherapy]] and [[radiation therapy]]<ref name="pmid11920484">{{cite journal| author=Nguyen NP, Sallah S, Karlsson U, Antoine JE| title=Combined chemotherapy and radiation therapy for head and neck malignancies: quality of life issues. | journal=Cancer | year= 2002 | volume= 94 | issue= 4 | pages= 1131-41 | pmid=11920484 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11920484 }} </ref> | ||
| Line 171: | Line 177: | ||
* [[Hypertrophy]] of [[cricopharyngeal muscle]]s<ref name="BenedictSweet1955">{{cite journal|last1=Benedict|first1=Edward B.|last2=Sweet|first2=Richard H.|title=Dysphagia Due to Hypertrophy of the Cricopharyngeus Muscle or Hypopharyngeal Bar|journal=New England Journal of Medicine|volume=253|issue=26|year=1955|pages=1161–1162|issn=0028-4793|doi=10.1056/NEJM195512292532607}}</ref> | * [[Hypertrophy]] of [[cricopharyngeal muscle]]s<ref name="BenedictSweet1955">{{cite journal|last1=Benedict|first1=Edward B.|last2=Sweet|first2=Richard H.|title=Dysphagia Due to Hypertrophy of the Cricopharyngeus Muscle or Hypopharyngeal Bar|journal=New England Journal of Medicine|volume=253|issue=26|year=1955|pages=1161–1162|issn=0028-4793|doi=10.1056/NEJM195512292532607}}</ref> | ||
'''To review a complete list of dysphagia causes, click [[Dysphagia causes#Causes by Organ System|here]]''' | '''To review a complete list of dysphagia [[causes]], click [[Dysphagia causes#Causes by Organ System|here]]''' | ||
==Diagnosis== | ==Diagnosis== | ||
<br> | |||
{{familytree/start |summary=Dysphagia}} | {{familytree/start |summary=Dysphagia}} | ||
{{familytree | | | | | | | | A01 |A01=Patient with [[Dysphagia]]}} | {{familytree | | | | | | | | A01 |A01=Patient with [[Dysphagia]]}} | ||
{{familytree | | | | |,|-|-|-|^ | {{familytree | | | | |,|-|-|-|^|-|-|-|.| | | }} | ||
{{familytree | | | | B01 | {{familytree | | | | B01 | | | | | | B02 | | |B01=Difficulty in initiating a swallow<br>associated with [[cough]], [[choking]]<br> or nasal [[regurgitation]]|B02=Dysphagia to solids and liquids, or solids,<br>sensation of food stuck in [[esophagus]]<br>(seconds after initiating swallow) }} | ||
{{familytree | | | | |! | {{familytree | | | | |!| | | | | | | |!| }} | ||
{{familytree | | | | C01 | {{familytree | | | | C01 | | | | | | C02 | |C01=Oropharyngeal dysphagia|C02=Esophageal dysphagia}} | ||
{{familytree/end}}<br><br> | {{familytree/end}}<br><br> | ||
Shown below is an algorithm summarizing the diagnosis of [[Oropharyngeal dysphagia]] according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.<ref name="MalageladaBazzoli2015">{{cite journal|last1=Malagelada|first1=Juan-R.|last2=Bazzoli|first2=Franco|last3=Boeckxstaens|first3=Guy|last4=De Looze|first4=Danny|last5=Fried|first5=Michael|last6=Kahrilas|first6=Peter|last7=Lindberg|first7=Greger|last8=Malfertheiner|first8=Peter|last9=Salis|first9=Graciela|last10=Sharma|first10=Prateek|last11=Sifrim|first11=Daniel|last12=Vakil|first12=Nimish|last13=Le Mair|first13=Anton|title=World Gastroenterology Organisation Global Guidelines|journal=Journal of Clinical Gastroenterology|volume=49|issue=5|year=2015|pages=370–378|issn=0192-0790|doi=10.1097/MCG.0000000000000307}}</ref><ref name="EspitalierFanous2018">{{cite journal|last1=Espitalier|first1=F.|last2=Fanous|first2=A.|last3=Aviv|first3=J.|last4=Bassiouny|first4=S.|last5=Desuter|first5=G.|last6=Nerurkar|first6=N.|last7=Postma|first7=G.|last8=Crevier-Buchman|first8=L.|title=International consensus (ICON) on assessment of oropharyngeal dysphagia|journal=European Annals of Otorhinolaryngology, Head and Neck Diseases|volume=135|issue=1|year=2018|pages=S17–S21|issn=18797296|doi=10.1016/j.anorl.2017.12.009}}</ref><ref name="CookKahrilas1999">{{cite journal|last1=Cook|first1=Ian J.|last2=Kahrilas|first2=Peter J.|title=AGA technical review on management of oropharyngeal dysphagia|journal=Gastroenterology|volume=116|issue=2|year=1999|pages=455–478|issn=00165085|doi=10.1016/S0016-5085(99)70144-7}}</ref><br><br> | Shown below is an algorithm summarizing the [[diagnosis]] of [[Oropharyngeal dysphagia]] according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.<ref name="MalageladaBazzoli2015">{{cite journal|last1=Malagelada|first1=Juan-R.|last2=Bazzoli|first2=Franco|last3=Boeckxstaens|first3=Guy|last4=De Looze|first4=Danny|last5=Fried|first5=Michael|last6=Kahrilas|first6=Peter|last7=Lindberg|first7=Greger|last8=Malfertheiner|first8=Peter|last9=Salis|first9=Graciela|last10=Sharma|first10=Prateek|last11=Sifrim|first11=Daniel|last12=Vakil|first12=Nimish|last13=Le Mair|first13=Anton|title=World Gastroenterology Organisation Global Guidelines|journal=Journal of Clinical Gastroenterology|volume=49|issue=5|year=2015|pages=370–378|issn=0192-0790|doi=10.1097/MCG.0000000000000307}}</ref><ref name="EspitalierFanous2018">{{cite journal|last1=Espitalier|first1=F.|last2=Fanous|first2=A.|last3=Aviv|first3=J.|last4=Bassiouny|first4=S.|last5=Desuter|first5=G.|last6=Nerurkar|first6=N.|last7=Postma|first7=G.|last8=Crevier-Buchman|first8=L.|title=International consensus (ICON) on assessment of oropharyngeal dysphagia|journal=European Annals of Otorhinolaryngology, Head and Neck Diseases|volume=135|issue=1|year=2018|pages=S17–S21|issn=18797296|doi=10.1016/j.anorl.2017.12.009}}</ref><ref name="CookKahrilas1999">{{cite journal|last1=Cook|first1=Ian J.|last2=Kahrilas|first2=Peter J.|title=AGA technical review on management of oropharyngeal dysphagia|journal=Gastroenterology|volume=116|issue=2|year=1999|pages=455–478|issn=00165085|doi=10.1016/S0016-5085(99)70144-7}}</ref><br><br> | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | | | | | G01 | | |G01=Dysphagia}} | {{familytree | | | | | | | | | G01 | | |G01=Dysphagia}} | ||
{{familytree | | | | | | | | | |!| | | | | | }} | {{familytree | | | | | | | | | |!| | | | | | }} | ||
{{familytree | | | | | | | | | A01 | | {{familytree | | | | | | | | | A01 |-|-| A02| | | | |A01=History and [[Physical examination]]|A02=Identify alternate diagnoses such as [[xerostomia]], [[globus]], [[esophageal dysphagia]]}} | ||
{{familytree | | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | | | | | | | | | B01 | | {{familytree | | | | | | | | | B01 |-|-| B02| | | | |B01=Laboratory findings and CNS imaging|B02=Identify syndromes with specific treatment such as [[myasthenia gravis]], toxic and metabolic [[myopathies]], [[Brain tumor|CNS tumors]]}} | ||
{{familytree | | | | | | |,|-|-|^|-|-|.| | }} | {{familytree | | | | | | |,|-|-|^|-|-|.| | }} | ||
{{familytree | | | | | | C01 | | | | C02 | | |C01=No [[systemic disease]] identified|C02=[[Neuromuscular disease|Neuromuscular disorders]] without specific treatment}} | {{familytree | | | | | | C01 | | | | C02 | | |C01=No [[systemic disease]] identified|C02=[[Neuromuscular disease|Neuromuscular disorders]] without specific treatment}} | ||
| Line 195: | Line 201: | ||
{{familytree | | | |,|-|-|^|-|-|-|-|.|!| | | | }} | {{familytree | | | |,|-|-|^|-|-|-|-|.|!| | | | }} | ||
{{familytree | | | |!| | | | | | | | E02 | | | |E02=[[Dysphagia diagnostic study of choice#Video Fluoroscopic Swallowing Study|Videofluoroscopic swallowing]] +/-[[manometry]] (to characterise severity and mechanism of [[swallow]] dysfunction)}} | {{familytree | | | |!| | | | | | | | E02 | | | |E02=[[Dysphagia diagnostic study of choice#Video Fluoroscopic Swallowing Study|Videofluoroscopic swallowing]] +/-[[manometry]] (to characterise severity and mechanism of [[swallow]] dysfunction)}} | ||
{{familytree | | | |!| | | |,|-|-|-|+|-|-|-|.| | | | | }} | {{familytree | | | |!| | | |,|-|-|-|-|+|-|-|-|.| | | | | }} | ||
{{familytree | | | F01 | | F02 | | F03 | | F04 | |F01=Structural lesions with specific therapy such as [[zenker's diverticulum]], [[orophayngeal tumors]]|F02=Severe dysfunction or risk of [[aspiration pneumonia]] necessitating the institution of nonoral feeding, [[tracheostomy]]|F03=[[Dysphagia]] ammendable to [[Inferior pharyngeal constrictor muscle|cricophayngeal]] [[myotomy]]|F04=[[Dysphagia]] ammendable to specific therapy ([[diet]] modification, [[Swallowing Maneuvers|swallow therapy]] +/- nonoral feeding)}} | {{familytree | | | F01 | | F02 | | | F03 | | F04 | |F01=Structural lesions with specific therapy such as [[zenker's diverticulum]], [[orophayngeal tumors]]|F02=Severe dysfunction or risk of [[aspiration pneumonia]] necessitating the institution of nonoral feeding, [[tracheostomy]]|F03=[[Dysphagia]] ammendable to [[Inferior pharyngeal constrictor muscle|cricophayngeal]] [[myotomy]]|F04=[[Dysphagia]] ammendable to specific therapy ([[diet]] modification, [[Dysphagia medical therapy#Swallowing Maneuvers|swallow therapy]] +/- temporary nonoral feeding)}} | ||
{{familytree/end}}<br><br> | {{familytree/end}}<br><br> | ||
Shown below is an algorithm summarizing the diagnosis of [[Esophageal dysphagia]] according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.<ref name="MalageladaBazzoli2015">{{cite journal|last1=Malagelada|first1=Juan-R.|last2=Bazzoli|first2=Franco|last3=Boeckxstaens|first3=Guy|last4=De Looze|first4=Danny|last5=Fried|first5=Michael|last6=Kahrilas|first6=Peter|last7=Lindberg|first7=Greger|last8=Malfertheiner|first8=Peter|last9=Salis|first9=Graciela|last10=Sharma|first10=Prateek|last11=Sifrim|first11=Daniel|last12=Vakil|first12=Nimish|last13=Le Mair|first13=Anton|title=World Gastroenterology Organisation Global Guidelines|journal=Journal of Clinical Gastroenterology|volume=49|issue=5|year=2015|pages=370–378|issn=0192-0790|doi=10.1097/MCG.0000000000000307}}</ref><ref name="LiuAndrews2018">{{cite journal|last1=Liu|first1=Louis W C|last2=Andrews|first2=Christopher N|last3=Armstrong|first3=David|last4=Diamant|first4=Nicholas|last5=Jaffer|first5=Nasir|last6=Lazarescu|first6=Adriana|last7=Li|first7=Marilyn|last8=Martino|first8=Rosemary|last9=Paterson|first9=William|last10=Leontiadis|first10=Grigorios I|last11=Tse|first11=Frances|title=Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia|journal=Journal of the Canadian Association of Gastroenterology|volume=1|issue=1|year=2018|pages=5–19|issn=2515-2084|doi=10.1093/jcag/gwx008}}</ref><br> | Shown below is an algorithm summarizing the [[diagnosis]] of [[Esophageal dysphagia]] according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.<ref name="MalageladaBazzoli2015">{{cite journal|last1=Malagelada|first1=Juan-R.|last2=Bazzoli|first2=Franco|last3=Boeckxstaens|first3=Guy|last4=De Looze|first4=Danny|last5=Fried|first5=Michael|last6=Kahrilas|first6=Peter|last7=Lindberg|first7=Greger|last8=Malfertheiner|first8=Peter|last9=Salis|first9=Graciela|last10=Sharma|first10=Prateek|last11=Sifrim|first11=Daniel|last12=Vakil|first12=Nimish|last13=Le Mair|first13=Anton|title=World Gastroenterology Organisation Global Guidelines|journal=Journal of Clinical Gastroenterology|volume=49|issue=5|year=2015|pages=370–378|issn=0192-0790|doi=10.1097/MCG.0000000000000307}}</ref><ref name="LiuAndrews2018">{{cite journal|last1=Liu|first1=Louis W C|last2=Andrews|first2=Christopher N|last3=Armstrong|first3=David|last4=Diamant|first4=Nicholas|last5=Jaffer|first5=Nasir|last6=Lazarescu|first6=Adriana|last7=Li|first7=Marilyn|last8=Martino|first8=Rosemary|last9=Paterson|first9=William|last10=Leontiadis|first10=Grigorios I|last11=Tse|first11=Frances|title=Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia|journal=Journal of the Canadian Association of Gastroenterology|volume=1|issue=1|year=2018|pages=5–19|issn=2515-2084|doi=10.1093/jcag/gwx008}}</ref><br> | ||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | |A01=<div style="float: center; text-align: center; width: 15em;"> Esophageal dysphagia</div>}} | {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | |A01=<div style="float: center; text-align: center; width: 15em;"> [[Esophageal dysphagia]]</div>}} | ||
{{familytree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|.| | | | }} | {{familytree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|.| | | | }} | ||
{{familytree | | | | | | | B01 | | | | | | | | | | | B02 | | |B01=<div style="float: center; text-align: center; width: 10em;"> Dysphagia to solids and liquids</div>|B02=<div style="float: center; text-align: center; width: 10em;">Dysphagia to solids (may progress to liquids)</div>}} | {{familytree | | | | | | | B01 | | | | | | | | | | | B02 | | |B01=<div style="float: center; text-align: center; width: 10em;"> Dysphagia to solids and liquids</div>|B02=<div style="float: center; text-align: center; width: 10em;">Dysphagia to solids (may progress to liquids)</div>}} | ||
| Line 211: | Line 217: | ||
{{familytree | |,|-|^|-|.| | | |!| | | |!| | | |!| | | |!| | |!| | | |!| }} | {{familytree | |,|-|^|-|.| | | |!| | | |!| | | |!| | | |!| | |!| | | |!| }} | ||
{{familytree | F08 | | F01 | | F02 | | F03 | | F04 | | F05 | | F06 | | F07 |F08=[[Esophageal motility disorders|Primary motility disorders]]|F01=[[Esophageal motility disorders|Secondary motility disorders]]|F02=[[Scleroderma]]|F03=[[Achalasia]]|F04=[[Foreign body]]|F05=<div style="float: center; text-align: center; width: 5em;">[[Esophageal ring]] or [[eosinophilic esophagitis]]</div>|F06=<div style="float: center; text-align: center; width: 5em;">[[Esophageal stricture]] / [[GERD]]</div>|F07=<div style="float: center; text-align: center; width: 6em;">[[Esophageal carcinoma|Esophageal]] or [[stomach|cardia]] carcinomas</div>}} | {{familytree | F08 | | F01 | | F02 | | F03 | | F04 | | F05 | | F06 | | F07 |F08=[[Esophageal motility disorders|Primary motility disorders]]|F01=[[Esophageal motility disorders|Secondary motility disorders]]|F02=[[Scleroderma]]|F03=[[Achalasia]]|F04=[[Foreign body]]|F05=<div style="float: center; text-align: center; width: 5em;">[[Esophageal ring]] or [[eosinophilic esophagitis]]</div>|F06=<div style="float: center; text-align: center; width: 5em;">[[Esophageal stricture]] / [[GERD]]</div>|F07=<div style="float: center; text-align: center; width: 6em;">[[Esophageal carcinoma|Esophageal]] or [[stomach|cardia]] carcinomas</div>}} | ||
{{familytree | | | {{familytree | |!| | | |!| | | |!| | |!| | | | |!| | | |!| | |!| | | |!| | }} | ||
{{familytree | | | {{familytree | |!| | | |!| | | |!| | |!| | | | |!| | | |!| | |!| | | |!| | }} | ||
{{familytree | | | {{familytree | |`|-|-|-|^| G01 |^|-|-|'| | | | |`|-|-| G02 |-|^|-|-|-|'| |G01=[[Manometry]]|G02=[[Endoscopy]] (+/-esophageal [[biopsy]])}} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | {{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | }} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | {{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | }} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | | I02 | | | | |I02=<div style="float: center; text-align: left; width: 15em;">[[Esophagogram|Barium Swallow]] indicated when: <br> | {{familytree | | | | | | | | | | | | | | | | | | | | | I02 | | | | |I02=<div style="float: center; text-align: left; width: 15em; padding:1em;">[[Esophagogram|Barium Swallow]] indicated when:<br>❑ [[Endoscopy]] findings are normal<br>❑ Endoscopy is contraindicated due to:<br>❑ History of surgery for [[esophageal cancer|esophageal]]/[[laryngeal cancer]]<br>❑ History of radiation<br>❑ [[Caustic]] injury<br>❑ Complex [[esophageal stricture|stricture]]<br>❑ Risk of [[perforation]] <br>❑ [[Endoscopy]] access is limited </div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
==Treatment== | ==Treatment== | ||
Shown below is an algorithm summarizing the treatment of [[Oropharyngeal dysphagia]] according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.<ref name="MalageladaBazzoli2015">{{cite journal|last1=Malagelada|first1=Juan-R.|last2=Bazzoli|first2=Franco|last3=Boeckxstaens|first3=Guy|last4=De Looze|first4=Danny|last5=Fried|first5=Michael|last6=Kahrilas|first6=Peter|last7=Lindberg|first7=Greger|last8=Malfertheiner|first8=Peter|last9=Salis|first9=Graciela|last10=Sharma|first10=Prateek|last11=Sifrim|first11=Daniel|last12=Vakil|first12=Nimish|last13=Le Mair|first13=Anton|title=World Gastroenterology Organisation Global Guidelines|journal=Journal of Clinical Gastroenterology|volume=49|issue=5|year=2015|pages=370–378|issn=0192-0790|doi=10.1097/MCG.0000000000000307}}</ref><ref name="EspitalierFanous2018">{{cite journal|last1=Espitalier|first1=F.|last2=Fanous|first2=A.|last3=Aviv|first3=J.|last4=Bassiouny|first4=S.|last5=Desuter|first5=G.|last6=Nerurkar|first6=N.|last7=Postma|first7=G.|last8=Crevier-Buchman|first8=L.|title=International consensus (ICON) on assessment of oropharyngeal dysphagia|journal=European Annals of Otorhinolaryngology, Head and Neck Diseases|volume=135|issue=1|year=2018|pages=S17–S21|issn=18797296|doi=10.1016/j.anorl.2017.12.009}}</ref><ref name="CookKahrilas1999">{{cite journal|last1=Cook|first1=Ian J.|last2=Kahrilas|first2=Peter J.|title=AGA technical review on management of oropharyngeal dysphagia|journal=Gastroenterology|volume=116|issue=2|year=1999|pages=455–478|issn=00165085|doi=10.1016/S0016-5085(99)70144-7}}</ref><br><br> | Shown below is an algorithm summarizing the [[treatment]] of [[Oropharyngeal dysphagia]] according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.<ref name="MalageladaBazzoli2015">{{cite journal|last1=Malagelada|first1=Juan-R.|last2=Bazzoli|first2=Franco|last3=Boeckxstaens|first3=Guy|last4=De Looze|first4=Danny|last5=Fried|first5=Michael|last6=Kahrilas|first6=Peter|last7=Lindberg|first7=Greger|last8=Malfertheiner|first8=Peter|last9=Salis|first9=Graciela|last10=Sharma|first10=Prateek|last11=Sifrim|first11=Daniel|last12=Vakil|first12=Nimish|last13=Le Mair|first13=Anton|title=World Gastroenterology Organisation Global Guidelines|journal=Journal of Clinical Gastroenterology|volume=49|issue=5|year=2015|pages=370–378|issn=0192-0790|doi=10.1097/MCG.0000000000000307}}</ref><ref name="EspitalierFanous2018">{{cite journal|last1=Espitalier|first1=F.|last2=Fanous|first2=A.|last3=Aviv|first3=J.|last4=Bassiouny|first4=S.|last5=Desuter|first5=G.|last6=Nerurkar|first6=N.|last7=Postma|first7=G.|last8=Crevier-Buchman|first8=L.|title=International consensus (ICON) on assessment of oropharyngeal dysphagia|journal=European Annals of Otorhinolaryngology, Head and Neck Diseases|volume=135|issue=1|year=2018|pages=S17–S21|issn=18797296|doi=10.1016/j.anorl.2017.12.009}}</ref><ref name="CookKahrilas1999">{{cite journal|last1=Cook|first1=Ian J.|last2=Kahrilas|first2=Peter J.|title=AGA technical review on management of oropharyngeal dysphagia|journal=Gastroenterology|volume=116|issue=2|year=1999|pages=455–478|issn=00165085|doi=10.1016/S0016-5085(99)70144-7}}</ref><br><br> | ||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{familytree | | | | | | | | A01 |A01= }} | {{familytree | | | | | | | |,|-| A01 |-| A02 | | | |A01=<div style="float: center; text-align: center;">Systemic disease with specific therapy<br> such as [[myasthenia gravis]], [[myopathies]],<br> [[parkinson's disease]], [[infections]] and others</div>|A02=Treat the underlying disease}} | ||
{{familytree | | | | | | {{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | }} | ||
{{familytree | | | | {{familytree | | | | | | | |)|-| B01 |-| B02 | | |B01=[[brain tumor|CNS tumors]] and [[oropharyngeal cancer|oropharyngeal tumors]]|B02= [[Surgery|Surgical resection]], [[chemotherapy]] or [[radiotherapy]]}} | ||
{{familytree | | | |!| | | | | | | | | | | {{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | }} | ||
{{familytree | | | C01 | | | | | | | | | | {{familytree | | | C01 |-|-|+|-| C02 |-| C03 | | | |C01=[[Oropharyngeal dysphagia]]|C02=Structural disorders such as [[Tracheal rings|cervical webs]] <br>and rings, [[zenker's diverticulum]] and others|C03=Treatment of the [[disorder]] }} | ||
{{familytree | | | {{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | }} | ||
{{familytree | | {{familytree | | | | | | | |)|-| D01 |-| D02 | | | |D01=[[Medication]] [[side effects]]|D02=Discontinue [[medication]]}} | ||
{{familytree | |!| | | | | | | | | | | {{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | }} | ||
{{familytree | | {{familytree | | | | | | | |!| | | | |,|-| E01 |-| E02 | | | |E01=Severe dysfunction and <br>risk of [[aspiration pneumonia]]|E02=<div style="float: left; text-align: left;">❑ Non-oral feeding<br>❑ [[Tracheostomy]]</div>}} | ||
{{familytree | | | | | | | | | | |!| | | | | | {{familytree | | | | | | | |!| | | | |!| | | | | | | | | | | | }} | ||
{{familytree | | | | | | | | | | F01 | | | F02 |F01= |F02= }} | {{familytree | | | | | | | |`|-| F01 |+|-| F02 |-| F03 | |F01=<div style="float: center; text-align: center;">Neuromuscular disorder without specific therapy such as [[stroke]], dengerative diseases and others</div>|F02=[[Inferior pharyngeal constrictor muscle|Cricopharynegal]] dysfunction|F03= [[Inferior pharyngeal constrictor muscle|Cricopharyngeal]] [[myotomy]]}} | ||
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | }} | |||
{{familytree | | | | | | | | | | | | |`|-| G01 |-| G02 | |G01=Rehabilitation|G02=<div style="float: left; text-align: left;">❑ [[Dysphagia medical therapy#Swallowing Maneuvers|Swallowing maneuvers]] and [[Dysphagia medical therapy#postural techniques|postural techniques]]<br>❑ Dietary modification<br>❑ Temporary non-oral feeding<br></div>}} | |||
{{familytree/end}}<br><br> | {{familytree/end}}<br><br> | ||
Shown below is an algorithm summarizing the management of [[Esophageal dysphagia]] according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.<ref name="MalageladaBazzoli2015">{{cite journal|last1=Malagelada|first1=Juan-R.|last2=Bazzoli|first2=Franco|last3=Boeckxstaens|first3=Guy|last4=De Looze|first4=Danny|last5=Fried|first5=Michael|last6=Kahrilas|first6=Peter|last7=Lindberg|first7=Greger|last8=Malfertheiner|first8=Peter|last9=Salis|first9=Graciela|last10=Sharma|first10=Prateek|last11=Sifrim|first11=Daniel|last12=Vakil|first12=Nimish|last13=Le Mair|first13=Anton|title=World Gastroenterology Organisation Global Guidelines|journal=Journal of Clinical Gastroenterology|volume=49|issue=5|year=2015|pages=370–378|issn=0192-0790|doi=10.1097/MCG.0000000000000307}}</ref><ref name="LiuAndrews2018">{{cite journal|last1=Liu|first1=Louis W C|last2=Andrews|first2=Christopher N|last3=Armstrong|first3=David|last4=Diamant|first4=Nicholas|last5=Jaffer|first5=Nasir|last6=Lazarescu|first6=Adriana|last7=Li|first7=Marilyn|last8=Martino|first8=Rosemary|last9=Paterson|first9=William|last10=Leontiadis|first10=Grigorios I|last11=Tse|first11=Frances|title=Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia|journal=Journal of the Canadian Association of Gastroenterology|volume=1|issue=1|year=2018|pages=5–19|issn=2515-2084|doi=10.1093/jcag/gwx008}}</ref><br><br> | Shown below is an algorithm summarizing the management of [[Esophageal dysphagia]] according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.<ref name="MalageladaBazzoli2015">{{cite journal|last1=Malagelada|first1=Juan-R.|last2=Bazzoli|first2=Franco|last3=Boeckxstaens|first3=Guy|last4=De Looze|first4=Danny|last5=Fried|first5=Michael|last6=Kahrilas|first6=Peter|last7=Lindberg|first7=Greger|last8=Malfertheiner|first8=Peter|last9=Salis|first9=Graciela|last10=Sharma|first10=Prateek|last11=Sifrim|first11=Daniel|last12=Vakil|first12=Nimish|last13=Le Mair|first13=Anton|title=World Gastroenterology Organisation Global Guidelines|journal=Journal of Clinical Gastroenterology|volume=49|issue=5|year=2015|pages=370–378|issn=0192-0790|doi=10.1097/MCG.0000000000000307}}</ref><ref name="LiuAndrews2018">{{cite journal|last1=Liu|first1=Louis W C|last2=Andrews|first2=Christopher N|last3=Armstrong|first3=David|last4=Diamant|first4=Nicholas|last5=Jaffer|first5=Nasir|last6=Lazarescu|first6=Adriana|last7=Li|first7=Marilyn|last8=Martino|first8=Rosemary|last9=Paterson|first9=William|last10=Leontiadis|first10=Grigorios I|last11=Tse|first11=Frances|title=Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia|journal=Journal of the Canadian Association of Gastroenterology|volume=1|issue=1|year=2018|pages=5–19|issn=2515-2084|doi=10.1093/jcag/gwx008}}</ref><br><br> | ||
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{{familytree | | | A01 | | | | | | | | | | | | | | | |A01=Esophageal dysphagia}} | {{familytree | | | A01 | | | | | | | | | | | | | | | |A01=Esophageal dysphagia}} | ||
{{familytree | | | |!| | | | | | | | | | | | | | | | | }} | {{familytree | | | |!| | | | | | | | | | | | | | | | | }} | ||
{{familytree | | | B01 |-|-| B02 |-|-| B03 | | | |B01=Age>50 years, [[weight loss]],<br>[[anemia]] and other alarm<br>signs and symptoms|B02=Endoscopy +/- other imaging studies|B03=[[esophagectomy|Surgical resection]] or<br>[[chemotherapy]]of the detected<br>[[esophageal carcinoma]]}} | {{familytree | | | B01 |-|-| B02 |-|-| B03 | | | |B01=Age>50 years, [[weight loss]],<br>[[anemia]] and other alarm<br>[[signs]] and [[symptoms]]|B02=Endoscopy +/- other [[imaging]] studies|B03=[[esophagectomy|Surgical resection]] or<br>[[chemotherapy]]of the detected<br>[[esophageal carcinoma]]}} | ||
{{familytree | | | |!| | | | | | | | | | | | | }} | {{familytree | | | |!| | | | | | | | | | | | | }} | ||
{{familytree | | | C01 | | | | | | | | | | | |C01=No}} | {{familytree | | | C01 | | | | | | | | | | | |C01=No}} | ||
{{familytree | | | |!| | | | | | | | | | | | | }} | {{familytree | | | |!| | | | | | | | | | | | | }} | ||
{{familytree | | | D01 |-|-| D02 | | | | | | |D01=[[GERD]] symptoms|D02=[[Proton pump inhibitor]] trial for 4 weeks}} | {{familytree | | | D01 |-|-| D02 | | | | | | |D01=[[GERD]] [[symptoms]]|D02=[[Proton pump inhibitor]] trial for 4 weeks}} | ||
{{familytree | | | |!| | | | |!| | | | | | | }} | {{familytree | | | |!| | | | |!| | | | | | | }} | ||
{{familytree | | | E01 | | | |!| | | | | | |E01=No }} | {{familytree | | | E01 | | | |!| | | | | | |E01=No }} | ||
{{familytree | | | |!|,|-|-| E02 | | |E02=[[Dysphagia]] unresolved}} | {{familytree | | | |!|,|-|-| E02 | | |E02=[[Dysphagia]] unresolved}} | ||
{{familytree | | | |!|!| | | | | | | | | | | | }} | {{familytree | | | |!|!| | | | | | | | | | | | }} | ||
{{familytree | | | F01 |-|-| F02 | | | | | |F01=Structural or inflammatory<br>lesions detected on [[endoscopy]]<br>and/or [[esophagogram|barium swallow]]|F02= | {{familytree | | | F01 |-|-| F02 | | | | | |F01=Structural or [[inflammatory]]<br>[[lesions]] detected on [[endoscopy]]<br>and/or [[esophagogram|barium swallow]]|F02=Treat the detected [[lesions]]}} | ||
{{familytree | | | |!| | | | | | | | | | | | | }} | {{familytree | | | |!| | | | | | | | | | | | | }} | ||
{{familytree | | | G01 | | | | | | | | | | | | |G01=No}} | {{familytree | | | G01 | | | | | | | | | | | | |G01=No}} | ||
{{familytree | | | |!| | | | | | | | | | | | | }} | {{familytree | | | |!| | | | | | | | | | | | | }} | ||
{{familytree | | | H01 |-|-| H02 | | | | | |H01=Esophageal manometry|H02= | {{familytree | | | H01 |-|-| H02 | | | | | |H01=[[Esophageal]] [[manometry]]|H02=Treat the<br> detected [[Esophageal motility disorders|motility disorders]] }} | ||
{{familytree/end}} | {{familytree/end}} | ||
==Do's== | ==Do's== | ||
* | * Evaluate for [[drugs]] causing decreased [[Saliva|salivary flow]] or those causing esophageal mucosal injury. | ||
* Treat underlying disorders first. | |||
* | |||
* | |||
==Don'ts== | ==Don'ts== | ||
* | * Don't perform [[endoscopy]] in [[patients]] with a history of prior [[radiation]] or [[caustic]] injury, history of [[surgery]] for [[Laryngeal cancer|laryngeal]] or [[esophageal cancer]], complex [[esophageal stricture|stricture]] or risk of [[perforation]]. | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category: | [[Category:Up-To-Date]] | ||
[[Category: | [[Category:Primary care]] | ||
[[Category:Resident survival guide]] | [[Category:Resident survival guide]] | ||
[[Category: | [[Category:Up-To-Date]] | ||
Latest revision as of 14:05, 27 August 2020
| Dysphagia Resident Survival Guide |
|---|
| Overview |
| Causes |
| Diagnosis |
| Treatment |
| Do's |
| Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Reddy Vadiyala, M.B.B.S.[2]
Synonyms and keywords: Approach to dysphagia, Dysphagia algorithm, Dysphagia workup, Dysphagia management, Dysphagia diagnostic approach
For the WikiDoc page for this topic, click here
Overview
Dysphagia is defined as "difficulty swallowing." It is a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach. According to the International Classification of Diseases (ICD-10) which is endorsed by the WHO, dysphagia is a symptom rather than a disease. Dysphagia can result from propulsive failure, motility disorders, structural disorders, intrinsic or extrinsic compression of the oropharynx or esophagus. Dysphagia is distinguished from similar symptoms including odynophagia, which is defined as painful swallowing, and globus, which is the sensation of a lump in the throat. The endoscopy for esophageal dysphagia should be performed when the patient presented with symptoms of difficulty swallowing, painful swallowing, and aspiration. This is the standard test performed when the patient has a risk of developing pneumonia and diagnosing swallowing difficulties. Videofluoroscopic swallowing study is performed for oropharyngeal dysphagia. It provides information about delay in initiation of pharyngeal swallowing, nasopharyngeal regurgitation, residue of ingested food within the pharyngeal cavity after swallowing, and aspiration of ingested food. The cornerstone of any dysphagia evaluation is a detailed history and a thorough review of symptoms that can differentiate esophageal from oropharyngeal dysphagia and help predict the specific etiology of dysphagia with an accuracy of approximately 80% confirmed by specific testing. How a patient describes his or her difficulty and its timing, associated symptoms, and other characterizations may specifically denote the anatomic level of swallowing dysfunction.
Causes
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. There are no known life-threatening causes of dysphagia.
Common Causes
Depending upon the type of dysphagia, the causes can be categorized into two subsections:[1][2][3][4][5][6]
Common Causes of Oropharyngeal Dysphagia
| Common causes of oropharyngeal dysphagia | |||
|---|---|---|---|
| Neuromuscular disorders | Mechanical and obstructive causes | Medication side effects | Others |
|
Medications that reduce salivary flow:
|
||
Common Causes of Esophageal Dysphagia
The common causes of esophageal dysphagia can be divided into four categories.[7][8][9][10][11]
| Structural (Mechanical) disorders | Motor disorders | Esophageal tumors | Systemic diseases | Miscellaneous | ||||
|---|---|---|---|---|---|---|---|---|
| Intrinsic compression | Extrinsic Compression | Primary | Secondary | |||||
Mucosal rings and webs
|
Strictures: | Vascular compression:
|
|
|
|
| ||
Less Common Causes
Less common causes of dysphagia include:
- Scleredema adultorum[12][13]
- Post chemotherapy and radiation therapy[14]
- Descending thoracic aorta aneurysm[15]
- Hypertrophy of cricopharyngeal muscles[16]
To review a complete list of dysphagia causes, click here
Diagnosis
| Patient with Dysphagia | |||||||||||||||||||||||||||||||
| Difficulty in initiating a swallow associated with cough, choking or nasal regurgitation | Dysphagia to solids and liquids, or solids, sensation of food stuck in esophagus (seconds after initiating swallow) | ||||||||||||||||||||||||||||||
| Oropharyngeal dysphagia | Esophageal dysphagia | ||||||||||||||||||||||||||||||
Shown below is an algorithm summarizing the diagnosis of Oropharyngeal dysphagia according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.[1][4][2]
| Dysphagia | |||||||||||||||||||||||||||||||||||||||||||
| History and Physical examination | Identify alternate diagnoses such as xerostomia, globus, esophageal dysphagia | ||||||||||||||||||||||||||||||||||||||||||
| Laboratory findings and CNS imaging | Identify syndromes with specific treatment such as myasthenia gravis, toxic and metabolic myopathies, CNS tumors | ||||||||||||||||||||||||||||||||||||||||||
| No systemic disease identified | Neuromuscular disorders without specific treatment | ||||||||||||||||||||||||||||||||||||||||||
| Nasoendoscopy (to evaluate for structural causes of dysphagia) | |||||||||||||||||||||||||||||||||||||||||||
| Videofluoroscopic swallowing +/-manometry (to characterise severity and mechanism of swallow dysfunction) | |||||||||||||||||||||||||||||||||||||||||||
| Structural lesions with specific therapy such as zenker's diverticulum, orophayngeal tumors | Severe dysfunction or risk of aspiration pneumonia necessitating the institution of nonoral feeding, tracheostomy | Dysphagia ammendable to cricophayngeal myotomy | Dysphagia ammendable to specific therapy (diet modification, swallow therapy +/- temporary nonoral feeding) | ||||||||||||||||||||||||||||||||||||||||
Shown below is an algorithm summarizing the diagnosis of Esophageal dysphagia according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.[1][6]
Dysphagia to solids and liquids | Dysphagia to solids (may progress to liquids) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Motility disorders | Mechanical obstruction | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Intermittent | Progressive | Acute | Intermittent | Progressive | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Chronic heartburn | Regurgitation and/or respiratory symptoms | Chronic heartburn | Elderly (>50 years), weight loss, anemia | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Primary motility disorders | Secondary motility disorders | Scleroderma | Achalasia | Foreign body | Esophageal or cardia carcinomas | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Manometry | Endoscopy (+/-esophageal biopsy) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Barium Swallow indicated when: ❑ Endoscopy findings are normal ❑ Endoscopy is contraindicated due to: ❑ History of surgery for esophageal/laryngeal cancer ❑ History of radiation ❑ Caustic injury ❑ Complex stricture ❑ Risk of perforation ❑ Endoscopy access is limited | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the treatment of Oropharyngeal dysphagia according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.[1][4][2]
Systemic disease with specific therapy such as myasthenia gravis, myopathies, parkinson's disease, infections and others | Treat the underlying disease | ||||||||||||||||||||||||||||||||||||||||||||||||||
| CNS tumors and oropharyngeal tumors | Surgical resection, chemotherapy or radiotherapy | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Oropharyngeal dysphagia | Structural disorders such as cervical webs and rings, zenker's diverticulum and others | Treatment of the disorder | |||||||||||||||||||||||||||||||||||||||||||||||||
| Medication side effects | Discontinue medication | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Severe dysfunction and risk of aspiration pneumonia | ❑ Non-oral feeding ❑ Tracheostomy | ||||||||||||||||||||||||||||||||||||||||||||||||||
Neuromuscular disorder without specific therapy such as stroke, dengerative diseases and others | Cricopharynegal dysfunction | Cricopharyngeal myotomy | |||||||||||||||||||||||||||||||||||||||||||||||||
| Rehabilitation | |||||||||||||||||||||||||||||||||||||||||||||||||||
Shown below is an algorithm summarizing the management of Esophageal dysphagia according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.[1][6]
| Esophageal dysphagia | |||||||||||||||||||||||||||||||||||||||||
| Age>50 years, weight loss, anemia and other alarm signs and symptoms | Endoscopy +/- other imaging studies | Surgical resection or chemotherapyof the detected esophageal carcinoma | |||||||||||||||||||||||||||||||||||||||
| No | |||||||||||||||||||||||||||||||||||||||||
| GERD symptoms | Proton pump inhibitor trial for 4 weeks | ||||||||||||||||||||||||||||||||||||||||
| No | |||||||||||||||||||||||||||||||||||||||||
| Dysphagia unresolved | |||||||||||||||||||||||||||||||||||||||||
| Structural or inflammatory lesions detected on endoscopy and/or barium swallow | Treat the detected lesions | ||||||||||||||||||||||||||||||||||||||||
| No | |||||||||||||||||||||||||||||||||||||||||
| Esophageal manometry | Treat the detected motility disorders | ||||||||||||||||||||||||||||||||||||||||
Do's
- Evaluate for drugs causing decreased salivary flow or those causing esophageal mucosal injury.
- Treat underlying disorders first.
Don'ts
- Don't perform endoscopy in patients with a history of prior radiation or caustic injury, history of surgery for laryngeal or esophageal cancer, complex stricture or risk of perforation.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Malagelada, Juan-R.; Bazzoli, Franco; Boeckxstaens, Guy; De Looze, Danny; Fried, Michael; Kahrilas, Peter; Lindberg, Greger; Malfertheiner, Peter; Salis, Graciela; Sharma, Prateek; Sifrim, Daniel; Vakil, Nimish; Le Mair, Anton (2015). "World Gastroenterology Organisation Global Guidelines". Journal of Clinical Gastroenterology. 49 (5): 370–378. doi:10.1097/MCG.0000000000000307. ISSN 0192-0790.
- ↑ 2.0 2.1 2.2 Cook, Ian J.; Kahrilas, Peter J. (1999). "AGA technical review on management of oropharyngeal dysphagia". Gastroenterology. 116 (2): 455–478. doi:10.1016/S0016-5085(99)70144-7. ISSN 0016-5085.
- ↑ Philpott, Hamish; Garg, Mayur; Tomic, Dunya; Balasubramanian, Smrithya; Sweis, Rami (2017). "Dysphagia: Thinking outside the box". World Journal of Gastroenterology. 23 (38): 6942–6951. doi:10.3748/wjg.v23.i38.6942. ISSN 1007-9327.
- ↑ 4.0 4.1 4.2 Espitalier, F.; Fanous, A.; Aviv, J.; Bassiouny, S.; Desuter, G.; Nerurkar, N.; Postma, G.; Crevier-Buchman, L. (2018). "International consensus (ICON) on assessment of oropharyngeal dysphagia". European Annals of Otorhinolaryngology, Head and Neck Diseases. 135 (1): S17–S21. doi:10.1016/j.anorl.2017.12.009. ISSN 1879-7296.
- ↑ Abdel Jalil, Ala' A.; Katzka, David A.; Castell, Donald O. (2015). "Approach to the Patient with Dysphagia". The American Journal of Medicine. 128 (10): 1138.e17–1138.e23. doi:10.1016/j.amjmed.2015.04.026. ISSN 0002-9343.
- ↑ 6.0 6.1 6.2 Liu, Louis W C; Andrews, Christopher N; Armstrong, David; Diamant, Nicholas; Jaffer, Nasir; Lazarescu, Adriana; Li, Marilyn; Martino, Rosemary; Paterson, William; Leontiadis, Grigorios I; Tse, Frances (2018). "Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia". Journal of the Canadian Association of Gastroenterology. 1 (1): 5–19. doi:10.1093/jcag/gwx008. ISSN 2515-2084.
- ↑ Xiao Y, Kahrilas PJ, Nicodème F, Lin Z, Roman S, Pandolfino JE (2014). "Lack of correlation between HRM metrics and symptoms during the manometric protocol". Am J Gastroenterol. 109 (4): 521–6. doi:10.1038/ajg.2014.13. PMC 4120962. PMID 24513804.
- ↑ Enestvedt BK, Williams JL, Sonnenberg A (2011). "Epidemiology and practice patterns of achalasia in a large multi-centre database". Aliment Pharmacol Ther. 33 (11): 1209–14. doi:10.1111/j.1365-2036.2011.04655.x. PMC 3857989. PMID 21480936.
- ↑ Howard PJ, Maher L, Pryde A, Cameron EW, Heading RC (1992). "Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh". Gut. 33 (8): 1011–5. PMC 1379432. PMID 1398223.
- ↑ Pandolfino JE, Gawron AJ (2015). "Achalasia: a systematic review". JAMA. 313 (18): 1841–52. doi:10.1001/jama.2015.2996. PMID 25965233.
- ↑ Gockel I, Lord RV, Bremner CG, Crookes PF, Hamrah P, DeMeester TR (2003). "The hypertensive lower esophageal sphincter: a motility disorder with manometric features of outflow obstruction". J Gastrointest Surg. 7 (5): 692–700. PMID 12850684.
- ↑ Chatterjee S, Hedman BJ, Kirby DF (2017). "An Unusual Cause of Dysphagia". J Clin Rheumatol. doi:10.1097/RHU.0000000000000666. PMID 29280826.
- ↑ Wright RA, Bernie H (1982). "Scleredema adultorum of Buschke with upper esophageal involvement". Am J Gastroenterol. 77 (1): 9–11. PMID 7064968.
- ↑ Nguyen NP, Sallah S, Karlsson U, Antoine JE (2002). "Combined chemotherapy and radiation therapy for head and neck malignancies: quality of life issues". Cancer. 94 (4): 1131–41. PMID 11920484.
- ↑ Conte, Blagio A. (1966). "Dysphagia Caused by an Aneurysm of the Descending Thoracic Aorta". New England Journal of Medicine. 274 (17): 956–957. doi:10.1056/NEJM196604282741710. ISSN 0028-4793.
- ↑ Benedict, Edward B.; Sweet, Richard H. (1955). "Dysphagia Due to Hypertrophy of the Cricopharyngeus Muscle or Hypopharyngeal Bar". New England Journal of Medicine. 253 (26): 1161–1162. doi:10.1056/NEJM195512292532607. ISSN 0028-4793.