GASTROINTESTINAL Last edited: 3/4/2024

1. DYSPHAGIA
I. PATHOPHYSIOLOGY AND CAUSES II. CLASSIC FINDINGS OF DYSPHAGIA III. DIAGNOSTIC APPROACH TO DYSPHAGIA
A. OROPHARYNGEAL DYSPHAGIA A. OROPHARYNGEAL DYSPHAGIA A. ASSESS FOR OROPHARYNGEAL DYSPHAGIA:
B. ESOPHAGEAL DYSPHAGIA B. ESOPHAGEAL DYSPHAGIA B. ASSESS FOR ESOPHAGEAL DYSPHAGIA

00:50
I. Pathophysiology and Causes
A. Oropharyngeal Dysphagia
1. Pathophysiology: 2. Causes of Oropharyngeal Dysphagia:
o Structural outpouching or neuromuscular dysfunction →
a) Structural Causes:
Inability to initiate swallowing and propulsion of foods and
fluids into the esophagus i) Zenker’s Diverticulum
o Associated with the Weakness of Inferior Pharyngeal
Constrictors and ↑intraluminal pressure → Outpouching
above the upper esophageal sphincter
 Often associated with Halitosis and Regurgitation

Zenker’s
Difficulty Diverticulum
Pharynx
initiating UES
swallowing Esophagus

b) Neuromuscular Causes
i) ALS, CVA, Parkinson’s Disease
o Associated with ↓Firing of CNS neurons going to the
pharyngeal muscles → Causing the inability to swallow and
propel food into the esophagus
 Often associated with underlying neurologic deficits

ii) Myasthenia Gravis

o Associated with ↓Pharyngeal muscle contraction
secondary to autoantibodies attacking the Acetylcholine
receptors at the neuromuscular junction
 Often associated with dysarthria, diplopia, extraocular
muscle weakness

NMJ Disorder
Myasthenia gravis
Pharynx

- Propulsion

Esophagus
CNS disorders
ALS
Parkinson’s
Multiple Sclerosis

Dysphagia GASTROINTESTINAL : Note #1 1 of 4

 B. Esophageal Dysphagia 07:39

1. Pathophysiology: Difficulty
moving
o Esophageal obstruction or neuromuscular dysfunction of the food/fluid
esophagus → Inability to move foods and fluids through the through
esophagus esophagus

2. Causes of Esophageal Dysphagia:

a) Structural Causes b) Neuromuscular Causes
i) Esophagitis/Esophageal Strictures i) Achalasia
o Inflammation and Fibrosis o ↓Activity of Myenteric Plexus in esophagus →
of Esophageal Lining → ↓Peristalsis of the Mid-
Esophagitis
Narrowing of the esophageal Distal Esophagus and
lumen → Difficulty moving Strictures ↑Lower esophageal Contractility
food/fluids through the sphincter (LES) tone → of esophagus
esophagus Dilation of esophagus LES pressure
 Assess for history of Chronic GERD proximal to LES
 Assess for:
Achalasia
ii) Esophageal Webs Toxic Megacolon, Achalasia, and Dilated Cardiomyopathy in
Asymmetric thin membrane that protrudes into the Upper Chagas Disease (secondary to Trypanosoma cruzi)
Esophagus lumen → Narrowing of the esophageal lumen →
Difficulty moving food/fluids through the esophagus
 Assess for Plummer-
ii) Diffuse Esophageal Spasm
Vinson syndrome Esophageal o Abnormal myenteric activity →
↑Peristalsis of the Mid-Distal
• Iron deficiency anemia Web
Esophagus and normal lower
• Dysphagia Contractility
esophageal sphincter (LES) tone
• Esophageal webs Upper of esophagus
→ Corkscrew appearance of the
esophagus LES pressure
mid-distal esophagus
 May present with: Esophageal
iii) Schatzki Rings Severe chest pain Spasm
o Circular thin membrane
that protrudes into the Esophageal
Lower Esophagus lumen → ring iii) Scleroderma
Narrowing of the esophageal o Atrophy and fibrosis of the esophageal muscle →
lumen → Difficulty moving Lower ↓Peristalsis of the Mid-Distal Esophagus and ↓Lower
food/fluids through the esophagus
esophageal sphincter (LES) tone
esophagus
 May be associated with CREST findings:
 Assess for history of Chronic GERD
• Calcinosis
iv) Esophageal Cancer • Raynaud’s phenomenon Contractility
o Esophageal mass obstructs of esophagus
• Esophageal dysmotility
the esophageal lumen → Esophageal • Sclerodactyly LES pressure
Narrowing of the esophageal Cancer • Telangiectasia
lumen → Scleroderma
Difficulty moving food/fluids through the esophagus
 Assess for anemia/weight loss

II. Classic Findings of Dysphagia

A. Oropharyngeal Dysphagia B. Esophageal Dysphagia
Difficulty with initiation of swallowing The sensation of food being stuck in the esophagus
o Associated with drooling, regurgitation, choking, and coughing o Associated with heartburn, chest pain, and
as a sign of possible nasopharyngeal reflux and aspiration regurgitation

2 of 4 GASTROINTESTINAL : Note #1 Dysphagia

 18:01
III. Diagnostic Approach to Dysphagia

A. Assess for Oropharyngeal Dysphagia:

1. Obtain Barium Swallow
Indications:
o Assess for Zenker’s Diverticulum
o Assess for findings suggestive of Esophageal Dysphagia
Findings suggestive of Zenker's Diverticulum:
o The presence of an out-pouch filling with barium above the
upper esophageal sphincter → Zenker’s Diverticulum
 The presence of no out-pouching requires further workup for
neuromuscular diseases

Zenker’s Diverticulum

Dysphagia GASTROINTESTINAL : Note #1 3 of 4

 B. Assess for Esophageal Dysphagia
1. Obtain Barium Swallow 3. Obtain Esophageal Manometry
Indications: Indications:
o Assess for Zenker’s Diverticulum o Assess for more specific neuromuscular causes of Esophageal
o Assess for findings suggestive of Esophageal Dysphagia Dysphagia
Abnormal Findings: Abnormal Findings:
o Narrowing of the lower esophagus may suggest: o ↓Peristalsis of the mid-distal esophagus and ↑Lower
 Esophagitis esophageal sphincter (LES) tone → Achalasia
 Stricture o ↑Peristalsis of the mid-distal esophagus and normal Lower
 Schatzki Ring esophageal sphincter (LES) tone → Diffuse Esophageal Spasm
 Esophageal Cancer o ↓Peristalsis of the mid-distal esophagus and ↓Lower
o Asymmetric narrowing of the upper esophagus suggests: esophageal sphincter (LES) tone → Scleroderma
Esophageal Web
o Corkscrew appearance of the mid-distal esophagus suggests
Diffuse Esophageal Spasm
o Dilation of mid-distal esophagus with tapering at distal
esophagus in a “Bird’s Beak Appearance” suggests Achalasia

2. Obtain Esophageal Gastroduodenoscopy (EGD)

Indications:
o Assess for more specific structural causes of Esophageal
Dysphagia
 Rule out neuromuscular causes of Esophageal Dysphagia
Abnormal Findings:
o Narrowing of the lower esophagus may suggest Esophagitis,
Stricture, Schatzki Ring, Esophageal Cancer

Schatzki Ring
 Biopsy may confirm Stricture vs Esophagitis vs Cancer
• Appearance of asymmetric thin esophageal membrane
plus presence of Plummer-Vinson Syndrome →
Esophageal Web

4 of 4 GASTROINTESTINAL : Note #1 Dysphagia