Dysphagia: Evaluation and Collaborative Management

 

Am Fam Physician. 2021 Jan 15;103(2):97-106.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/dysphagia.

Author disclosure: No relevant financial affiliations.

Dysphagia is common but may be underreported. Specific symptoms, rather than their perceived location, should guide the initial evaluation and imaging. Obstructive symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions. Oropharyngeal dysphagia manifests as difficulty initiating swallowing, coughing, choking, or aspiration, and it is most commonly caused by chronic neurologic conditions such as stroke, Parkinson disease, or dementia. Symptoms should be thoroughly evaluated because of the risk of aspiration. Patients with esophageal dysphagia may report a sensation of food getting stuck after swallowing. This condition is most commonly caused by gastroesophageal reflux disease and functional esophageal disorders. Eosinophilic esophagitis is triggered by food allergens and is increasingly prevalent; esophageal biopsies should be performed to make the diagnosis. Esophageal motility disorders such as achalasia are relatively rare and may be overdiagnosed. Opioid-induced esophageal dysfunction is becoming more common. Esophagogastroduodenoscopy is recommended for the initial evaluation of esophageal dysphagia, with barium esophagography as an adjunct. Esophageal cancer and other serious conditions have a low prevalence, and testing in low-risk patients may be deferred while a four-week trial of acid-suppressing therapy is undertaken. Many frail older adults with progressive neurologic disease have significant but unrecognized dysphagia, which significantly increases their risk of aspiration pneumonia and malnourishment. In these patients, the diagnosis of dysphagia should prompt a discussion about goals of care before potentially harmful interventions are considered. Speech-language pathologists and other specialists, in collaboration with family physicians, can provide structured assessments and make appropriate recommendations for safe swallowing, palliative care, or rehabilitation.

Many people occasionally experience difficult or impaired swallowing, but they often adapt their eating patterns to their symptoms and do not seek medical attention.1 Among those who do seek care, the most common causes are generally benign and self-limited, and serious or life-threatening conditions are rare. However, many older adults with progressive neurologic disease have significant but unrecognized dysphagia, which increases their risk of aspiration pneumonia and malnourishment. In these patients, the diagnosis of dysphagia should prompt a discussion about goals of care. Understanding the basic pathophysiology of swallowing and the etiologies and clinical presentations of dysphagia allows family physicians to distinguish between oropharyngeal and esophageal pathology, make informed management decisions, and collaborate appropriately with specialists.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Patients younger than 50 years who have esophageal dysphagia and no other worrisome symptoms should undergo a four-week trial of acid suppression therapy before endoscopy is performed.9,26,27

B

CAG and ACG guidelines; systematic review of seven retrospective cohort studies showing a positive predictive value of less than 1% for malignancy

Patients with apparent oropharyngeal symptoms but a negative evaluation should be referred for EGD to rule out esophageal pathology.28

C

Retrospective review of 3,668 consecutive patients; distal esophageal pathology was incorrectly perceived as arising from the neck or throat in 15% to 30% of cases

EGD is recommended for the initial assessment of patients with esophageal dysphagia; barium esophagography is recommended as an adjunct if EGD findings are negative.9,29,30

C

CAG, STS, and WGO guidelines; expert consensus based on limited evidence and cost-analysis; EGD has greater sensitivity and specificity than barium esophagography, with greater cost-effectiveness

For accurate diagnosis of eosinophilic esophagitis, biopsies from normal-appearing mucosa in the midthoracic and distal esophagus should be requested for all patients with unexplained solid food dysphagia.15,17

B

Expert consensus recommendation based on CAG, ACG, and AGA guidelines; early-stage eosinophilic esophagitis may not exhibit mucosal changes on endoscopy

Older patients with chronic illness or recent pneumonia should be screened for dysphagia; if it is present, the physician and patient should discuss goals of care.22,43

C

Expert consensus on dysphagia as a geriatric syndrome


ACG = American College of Gastroenterology; AGA = American Gastroenterological Association; CAG = Canadian Association of Gastroenterology; EGD = esophagogastroduodenoscopy; STS = Society of Thoracic Surgeons; WGO = World Gastroenterology Organisation.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disea

The Authors

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JOHN M. WILKINSON, MD, is a consultant in the Department of Family Medicine and an associate professor in the Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn....

DON CHAMIL CODIPILLY, MD, is a fellow in the Division of Gastroenterology and Hepatology at Mayo Clinic College of Medicine and Science.

ROBERT P. WILFAHRT, MD, is a consultant in the Department of Family Medicine and an assistant professor in the Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science.

Address correspondence to John M. Wilkinson, MD, Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, 200 1st St. SW, Rochester, MN 55905 (email: wilkinson.john@mayo.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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