Oesophagus and stomach

Curriculum based clinical review

Curriculum review : investigation

and management of dysphagia
Gaurav B Nigam ‍ ‍,1,2 Dipesh Harshvadan Vasant ‍ ‍,3,4 Anjan Dhar ‍ ‍5,6

1
Translational Gastroenterology Abstract This is a focused review for the manage-
Unit, Oxford University Hospitals,
Oxford, UK
Dysphagia is a common presentation in ment of dysphagia based on the current
2
National Institute of Health gastroenterology practice and the diagnosis and specialty training curriculum for gastro-
Research, Oxford, UK
3
management requires a comprehensive knowledge enterology in the UK (figure 1). It will
Neurogastroenterology
Unit, Wythenshawe Hospital,
of diverse range of aetiologies, with a systematic address the aetiology, clinical presen-
Manchester University NHS approach for assessment of symptoms, selection of tation, an approach to rational inves-
Foundation Trust, Manchester, UK
4
investigations and appropriate treatment to relieve tigations and treatment modalities for
Division of Diabetes,
Endocrinology and symptoms. In this curriculum review, the suggested managing patients with dysphagia.
Gastroenterology, The University diagnostic approach highlights the importance of
of Manchester, Manchester, UK thorough clinical assessment in order to guide the
5
Gastroenterology, Darlington Anatomy and physiology of
Memorial Hospital, Darlington, selection of investigations. This article discusses the swallowing
UK utility of endoscopic, histopathology, fluoroscopic Swallowing is divided into three anatom-
6
School of Health and Life and motility investigations for dysphagia, and their
Sciences, Teesside University, ical phases: the oral phase, where food
Middlesborough, UK interpretation, in order to guide targeted treatments is masticated and a bolus formed; the
ranging from dietary, pharmacological, endoscopic oropharyngeal phase, where the bolus is
Correspondence to and surgical interventions. propelled into the pharynx with protec-
Dr Gaurav B Nigam, Translational
Gastroenterology Unit, Oxford tive closure of the nasopharynx by the
University Hospitals NHS Trust, elevation of the soft palate and the closure
Oxford, UK; ​gaurav.​nigam@​ Introduction of the larynx by the epiglottis; the oesoph-
nhs.​net Dysphagia is defined as the subjective ageal phase where the bolus is transferred
Received 24 May 2021 awareness of a difficulty in the passage of to the stomach via a relaxed lower oesoph-
Accepted 7 July 2021 food from the oral cavity to the stomach. ageal sphincter (LOS). A detailed anatomy
Published Online First It can occur due to anatomical or phys-
3 August 2021 and physiology of normal and abnormal
iological dysfunction at the level of swallowing is beyond the scope of this
oropharynx or oesophagus and signifies a article and is discussed comprehensively
delay in bolus transit, or merely the sensa- in a recently published review article.1
tion thereof.1 Dysphagia may be associated
​fg.​bmj.​com with two other symptoms—odynophagia Initial assessment—clinical
and globus. Odynophagia is defined as history and physical
painful swallowing, whereas globus refers examination
to a persistent or intermittent non-­painful History
sensation of a lump, a retained food bolus A detailed clinical history to characterise
or tightness in the throat.2 dysphagia based on anatomical location
Dysphagia symptoms can range from (high/oropharyngeal vs low/oesopha-
difficulty initiating a swallow, to the aware- geal), underlying pathology (structural vs
ness of obstruction or sensation of food motility disorders), predominant symp-
getting stuck in the oesophagus. In clinical toms in relation to the food type (solid vs
practice, the presentation can be acute, or liquid or both) and progression (progres-
chronic. Acute dysphagia commonly pres- sive vs intermittent/non-­progressive) is an
ents to the emergency department as food important first step (figure 2).
© Author(s) (or their employer(s)) bolus obstruction, and is associated with Further history should then focus on
2022. No commercial re-­use. See
rights and permissions. Published
retrosternal chest pain. It may require associated features including: heartburn,
by BMJ. urgent endoscopic treatment to remove regurgitation, weight loss, anaemia, other
the food bolus. Chronic presentations systemic features, medical history with
To cite: Nigam GB,
Vasant DH, Dhar A. warrant a thorough clinical history and specific attention to neurological disor-
Frontline Gastroenterology diagnostic evaluation followed by use of ders, diabetes mellitus and/or rheumato-
2022;13:254–261.
appropriate treatment modalities. logical conditions. A detailed history of

254 Nigam GB, et al. Frontline Gastroenterology 2022;13:254–261. doi:10.1136/flgastro-2021-101917

 Oesophagus and stomach

Figure 1 The Joint Royal Colleges of Physicians Training Board 2010 gastroenterology curriculum—competencies for dysphagia.

the intake of medications that might affect oesoph- categorise high-­risk patients (EDS ⩾3.5) and prioritise
ageal motility or predispose to reflux or candidiasis, a 2-­week wait referral to exclude cancer.4 5
including non-­ steroidal anti-­ inflammatory drugs,
antibiotics, anticholinergics, sedatives, opiates and Physical examination
bisphosphonates, is recommended. Although physical examination is generally unremark-
The current UK cancer referral guidelines recom- able for oesophageal dysphagia, it can be of impor-
mend an oesophagogastroduodenoscopy (OGD) for tance in oropharyngeal dysphagia and/or underlying
all patients presenting with a new onset dysphagia, systemic causes. When oropharyngeal dysphagia
irrespective of age.3 The Edinburgh Dysphagia Score is suspected, an initial assessment should include—
(EDS) is a useful triage tool taking into consideration: inspection of oral cavity, examination of lower cranial
age, sex, weight loss, duration of symptoms, localisa- nerves and assessment of muscles of mastication, a
tion of dysphagia and acid reflux, and can be used to bedside water swallow test, local examination for

Figure 2 Approach to dysphagia.

Nigam GB, et al. Frontline Gastroenterology 2022;13:254–261. doi:10.1136/flgastro-2021-101917 255

Oesophagus and stomach

any neck or supraclavicular lymph-­nodes, thickening

Table 1 Differential diagnosis of dysphagia
of the soft tissues in the neck. Systemic examination
Oropharyngeal Structural ►► Zenker’s diverticulum/ pharyngeal pouch
looking for a skin rash and muscle wasting may give ►► Cricopharyngeal bar
clues for neurological and rheumatological condi- ►► Extrinsic compression (Cervical osteophytes,
thyromegaly, lymphadenopathy)
tions. ►► Oropharyngeal tumour
►► Radiation injury
►► Retropharyngeal abscess
Differential diagnosis Motility ►► Central/ Peripheral Nervous system
The causes of dysphagia can be broadly divided into –– Cerebrovascular accident
–– Intra-­cranial mass
oropharyngeal and oesophageal and are summarised ►► Neurodegenerative disease
in table 1. –– Multiple sclerosis
–– Parkinsonism
Oropharyngeal dysphagia is often managed by –– Alzheimer’s dementia
neurologists, ear, nose and throat (ENT) surgeons and –– Amyotrophic lateral sclerosis
–– Post-­polio syndrome
speech and language therapists (SLTs) and is therefore ►► Neuromuscular disease
beyond the focus of this review. The remainder of –– Botulism
–– Myasthenia Gravis
this review will therefore concentrate on oesophageal –– Lambert Eaton syndrome
causes with a brief discussion of relevant oropharyn- –– Muscular dystrophies
geal causes which may fall under the remit of gastro- –– Myopathies (Inflammatory, metabolic)
►► Medications
enterology practice. Oesophageal Structural ►► Oesophageal webs and rings
–– Schatzki ring Associated with EoE
–– Oesophageal strictures
Investigations –– Peptic stricture
–– Caustic ingestion
Videofluoroscopy
–– Pill-­induced (NSAIDs, antibiotics,
This provides a real-­time assessment of oropharyngeal bisphosphonates)
swallowing using boluses of different consistencies –– Radiation-­induced
–– Post-­surgical / ESD
mixed with barium under supervision of an SLT and ►► Oesophagitis
a radiologist. It is a useful assessment tool for evalu- –– Eosinophilic
–– Infectious
ation of oropharyngeal function and can guide SLT’s –– Pill or caustic
management and rehabilitation to optimise oropharyn- –– Reflux/ GORD
►► Anatomical abnormalities
geal coordination, minimise the risks of pulmonary –– Hiatus hernia
aspiration and inform recommendations on the most –– Oesophageal diverticulum
appropriate feeding consistencies.6 ►► Intramural growths
–– Leiomyoma
–– GIST
►► Extrinsic compression
Barium swallow –– Mediastinal mass
This involves asking the patient to swallow liquid or –– Aberrant right subclavian artery (dysphagia
lusoria)
semi-­solid barium sulphate followed by fluoroscopic ►► Malignancy
assessment to identify any structural or functional –– Primary oesophageal tumours (squamous,
adenocarcinoma)
abnormalities in the oesophagus. The sensitivity of the –– Secondary / metastatic (e.g. melanoma)
test can be enhanced by use of a variety of respiratory Motility ►► Disorders of Oesophagogastric junction (OGJ)
manoeuvres and by using 13 mm barium tablets or a outflow
–– Achalasia (Types I-­III)
solid bolus such as marshmallow or bread.7 Barium –– OGJ outflow obstruction
swallow can be a useful adjunctive test to a gastros- ►► Disorders of peristalsis
–– Absent contractility
copy depending on the initial presenting symptoms. –– Distal oesophageal spasm
For example, it is noted to be more sensitive for identi- –– Hypercontractile oesophagus
–– Ineffective oesophageal motility
fication of oesophageal rings and strictures which may ►► Secondary motility disorders
be missed on endoscopy and proves helpful for detec- –– Scleroderma
tion of proximal oesophageal lesions such as Zenker’s –– Other collagen vascular diseases
–– Amyloidosis
diverticulum/pharyngeal pouch, cricopharyngeal bars –– Diabetes
and postsurgical and/or radiation related injuries.6 EoE, eosinophilic oesophagitis; ESD, endoscopic sub-­mucosal dissection; GIST, gastro-­intestinal
Furthermore, a timed barium swallow has been shown stromal tumour; GORD, gastro-­oesophageal reflux disease; NSAID, non-­steroidal anti-­
inflammatory drug.
to be superior to endoscopy for evaluation of suspected
distal oesophageal motility disorders such as achalasia.
During a timed barium swallow, the height and area Oesophagogastroduodenoscopy
of the barium column is measured at 1, 2 and 5 min OGD is the most useful initial investigation for
after a drink and the percentage of barium retained is oesophageal dysphagia. Of all the imaging modalities,
calculated to quantify the effectiveness of a therapeutic endoscopy provides the most detailed information
procedure such as balloon dilatation or myotomy for on oesophageal anatomy, along with the capability
achalasia cardia.8 to assess the mucosa and obtain biopsies. It is most

256 Nigam GB, et al. Frontline Gastroenterology 2022;13:254–261. doi:10.1136/flgastro-2021-101917

 Oesophagus and stomach

useful to diagnose malignant, or pre-­malignant causes Treatment modalities

including strictures, dysplasia in Barrett’s oesophagus, The management of dysphagia involves a multidisci-
evaluate for eosinophilic oesophagitis (EoE), and can plinary approach often involving SLTs, dieticians, ENT
also be used for therapeutic interventions, when indi- and upper gastrointestinal surgeons, and gastroenter-
cated.9 ologists, with the aim to minimise morbidity related
Patients admitted with a food bolus obstruction to symptoms and to avoid risk of aspiration and
require an urgent referral to gastroenterology for food impaction. The various treatment modalities as
arranging endoscopy on the next available inpatient follows.
list. If there is associated severe retrosternal pain then
Diet
radiological imaging should be requested to rule out Nutrition
underlying perforation prior to the endoscopy. For It is vital to maintain appropriate caloric intake for
patients with spontaneous resolution of food bolus patients with dysphagia. Swallowing rehabilitation and
obstruction, an outpatient endoscopy with oesopha- re-­education along with modifications to the consist-
geal biopsies should be arranged. ency of the food supervised by SLTs and dieticians is an
A good quality examination should use high-­ important part of management especially in those with
definition endoscopy with good mucosal visualisa- oropharyngeal dysphagia. Oral feeding is preferable;
tion and photo-­documentation including images of however, alternative nutritional support in the form
the proximal and distal oesophagus. Oesophageal of enteral (radiological/endoscopic/surgical gastros-
biopsies should be obtained based on the clinical tomy or jejunostomy) and parenteral feeding should be
presentation and endoscopic findings with optimum considered in carefully selected cases.14 Modification
numbers (minimum of six) for suspected malig- of the consistency of food may be indicated for high
nancy.10 At least six samples (including the proximal oesophageal dysphagia and oropharyngeal transfer
and distal oesophagus) should be taken to diagnose dysphagia.
EoE in patients with dysphagia or food bolus obstruc-
tion with typical endoscopic findings as well as in Dietary therapy for EoE
the absence of typical findings if no other structural The use of a 2, 4 or 6-­food empiric elimination diet,
cause for dysphagia is identified.9 Current guidelines with exclusion of wheat, milk, egg, nuts, soy, fish and
recommend presence of ⩾15 eosinophils per high-­ shellfish may be considered as an anti-­inflammatory
power field on oesophageal biopsies as the cut-­off for treatment of EoE. This should be carried out only with
diagnosing EoE.11 the support of a specialist dietitian with appropriate
histological assessment to confirm improvement.
Elemental diet has also been conditionally recom-
Oesophageal manometry mended with moderate quality of evidence as per
High-­resolution oesophageal manometry (HROM) is recent guidelines.15
the gold standard test for the diagnosis of oesopha-
geal motility disorders. It involves recording pressure Pharmacological interventions
profiles of the oesophageal musculature and sphincters Proton pump inhibitors (PPIs) are often used where the
using water perfused or solid-­state transducers which cause of dysphagia is suspected to be related to gastro-­
can generate colorimetric pressure graphs (the Clouse oesophageal reflux disease, as well as in cases of EoE.
plot) using computer software (figure 3).12 Following an initial trial, if effective, longer-­term treat-
The findings of HROM form the basis for the hier- ment may be indicated. Around one-­third of patients
archical Chicago classification system which classi- with suspected EoE achieve remission with PPI, and
fies oesophageal motility disorders as (1) disorders of patients with persistent eosinophilia may be considered
oesophagogastric junction (OGJ) outflow (achalasia for topical corticosteroids (eg, orodispersible tablets
types I, II and III, and OGJ outflow obstruction) and/ of 1 mg budesonide administered two times a day).14
or (2) disorders of peristalsis (absent contractility, Biologic agents in the form of anti-­interleukin (IL)-­5
therapy (mepolizumab and reslizumab) and anti-­IL-­13
distal oesophageal spasm, hypercontractile oesoph-
agents (dupilumab) have shown promise in early clinical
agus and ineffective oesophageal motility). In all
trials for EoE and may be a future treatment option.15
subtypes of achalasia, there is failure of the LOS to
Medical therapies for motility disorders including:
relax in response to swallowing. The subclassification
oral nitrates, calcium channel blockers, prokinetics
of achalasia is based on the pattern of oesophageal
have limited efficacy and are often poorly tolerated,
body motility on HROM (figure 3).13 The clinical
but may be considered while planning definitive
responsiveness to the different treatment modalities therapy.14
appears to differ by achalasia subtype and therefore
their recognition can guide treatment. Endoscopic interventions
Figure 4 summarises the factors which influence the Endoscopic therapy plays an important role in the
selection of investigations in clinical practice. management of oesophageal dysphagia. Selection of

Nigam GB, et al. Frontline Gastroenterology 2022;13:254–261. doi:10.1136/flgastro-2021-101917 257

 Oesophagus and stomach

Figure 3 Oesophageal high resolution manometry—Clouse plots with colour coded oesophageal pressure heat maps—blue colour representing
low pressure and red colour representing high pressure zones. (A) Normal swallow—labelled landmarks of a normal pressure topography with
propagation of the swallow and relaxation of the lower oesophageal sphincter. (B) Type 1 achalasia—failed oesophageal peristalsis with failure
of lower oesophageal sphincter relaxation. (C) Type 2 achalasia—uniform, non-­propagating increase in oesophageal pressure (pan-­oesophageal
pressurisation) with failure of lower oesophageal sphincter to relax. (D) Type 3 (spastic) achalasia—premature, vigorous, contractions of the distal
oesophagus with failure of the lower oesopheageal sphincter to relax.

specific endoscopic therapies is guided by the under- 4 weeks once it has been achieved.18 The treatment
lying cause, and whether it is due to mechanical options for these include intralesional steroid injec-
obstruction or dysmotility. Table 2 provides a summary tions, endoscopic incisional therapy or oesophageal
of the various therapeutic options available and their stents.16
role in treating specific disorders. Oesophageal stents are also indicated in palliative
The British Society of Gastroenterology have management of advanced oesophageal cancers. There
provided guidelines on oesophageal dilatation in is a wide variety of oesophageal stents available in the
clinical practice.16 Two types of oesophageal dilators market and detailed discussion is beyond the scope of
are available: push/bougie dilator (longitudinal shear this review.19
force) or balloon dilator (radial shear force) and
have been shown to have similar clinical outcomes.17 Endoscopic interventions for achalasia
Although effective in relieving dysphagia due to stric- Recently, per-­oral endoscopic myotomy (POEM) has
tures, some patients may develop recurrent/refractory been used to create a submucosal tunnel to perform
benign oesophageal strictures. A refractory stricture is LOS myotomy with similar outcomes to laparoscopic
defined by the inability to maintain a luminal diam- Heller’s myotomy (LHM), and where expertise is
eter of ≥14 mm after five sequential dilatation sessions available, can be considered as a first-­line treatment
1–2 weeks apart, while a recurrent stricture is one with for achalasia, particularly in type III achalasia where
inability to maintain the target diameter of 14 mm for the length of the myotomy can be customised.20 21

258 Nigam GB, et al. Frontline Gastroenterology 2022;13:254–261. doi:10.1136/flgastro-2021-101917

 Oesophagus and stomach

Figure 4 Selection of appropriate investigation. ENT, ear, nose and throat surgeon; PPI, proton pump inhibitor; SLT, speech and language
therapist. *Barium swallow may be considered earlier in the algorithm when gastroscopy is not possible and/or where structural disorders require
further scrutiny (prior surgery, radiotherapy, caustic injury, complex stricture and so on).

Pneumatic balloon dilatation (PD) is a reasonable treat- Surgical interventions

ment option for achalasia types I & II but often requires Surgery is clearly indicated in the management of oper-
multiple graded procedures and is associated with post- able, malignant, oesophageal dysphagia. However, the
procedure reflux, carries up to 8% risk of perforation main role of surgery in benign dysphagia is limited
with a mortality of 0%–1% and has been shown to be to LHM for achalasia which has been shown to be a
inferior to both LHM and POEM.16 20 21 Botulinum highly effective treatment, with long-­term effects, and
toxin injection into the LOS does not have sustained has the added advantage compared with POEM and
benefit, and therefore is not recommended except in PD that it can be performed with a combined fundo-
those who are not candidates for definitive surgical or plication to reduce post-­myotomy reflux.21
more invasive endoscopic treatments.20
Percutaneous endoscopic gastrostomy tubes may be Conclusion
indicated in cases of dysphagia where oral feeding is This curriculum review summarises a practical and
not permissible, and the patient’s nutritional status systematic approach to the assessment, diagnosis and
indicate the need for nutritional support. management of dysphagia, and provides a framework

Table 2 Endoscopic therapies for dysphagia

Endoscopic therapy Aetiology for dysphagia
Oesophageal dilatation
►► Bougie and balloon dilator ►► Benign oesophageal strictures (peptic, EoE, caustic injury, drug-­induced, postsurgery, post-­radiation,
post-­endoscopic therapy), webs or rings (eg,Schatzki’s ring if symptomatic).
►► Malignant stricture for symptom relief.
►► Pneumatic balloon dilatation ►► Achalasia, OGJ outflow obstruction.
Botulinum toxin injection Achalasia and OGJ outflow obstruction in appropriately selected patients.
Intra-­luminal steroid injection Refractory benign oesophageal strictures.
Oesophageal stenting Benign refractory oesophageal strictures or Malignant stricture for palliative therapy.
Peroral endoscopic myotomy (POEM) Achalasia and OGJ outflow obstruction.
Percutaneous endoscopic gastrostomy Cases of dysphagia where oral feeding is not permissible.
EoE, eosinophilic oesophagitis; OGJ, oesophagogastric junction.

Nigam GB, et al. Frontline Gastroenterology 2022;13:254–261. doi:10.1136/flgastro-2021-101917 259

 Oesophagus and stomach
contributed to manuscript planning, reviewing and editing;
SCE questions (based on hypothetical clinical case provision of original images, responsible for overall content.
scenarios) AD contributed to manuscript planning, reviewing and editing,
responsible for overall content.
Question 1. A young man presents with an acute food bolus Funding The authors have not declared a specific grant for this
research from any funding agency in the public, commercial or
obstruction with retrosternal chest pain on a background not-­for-­profit sectors.
history of non-­progressive dysphagia to solids for 4 months.
Competing interests None declared.
An urgent endoscopy reveals that the food bolus has
cleared, and the oesophageal mucosa appears normal. What Patient consent for publication Not required.
should be the next step in the management? Provenance and peer review Not commissioned; externally
A. Barium swallow peer reviewed.
B. HROM ORCID iDs
C. Oesophageal biopsies Gaurav B Nigam http://orcid.org/0000-0003-4699-2263
Dipesh Harshvadan Vasant http://orcid.org/0000-0002-2329-​
D. A trial of PPI 0616
E. A recommendation for liquids only diet Anjan Dhar http://orcid.org/0000-0001-8964-2031
Answer: C
In patients presenting with chronic dysphagia and an acute
food bolus obstruction, the possibility of EoE, which is a
more common in this context, should be excluded as a
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