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.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
CAG and ACG guidelines; systematic review of seven retrospective cohort studies showing a positive predictive value of less than 1% for malignancy
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
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
Expert consensus recommendation based on CAG, ACG, and AGA guidelines; early-stage eosinophilic esophagitis may not exhibit mucosal changes on endoscopy
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
Referencesshow all references
1. Wilkins T, Gillies RA, Thomas AM, et al. The prevalence of dysphagia in primary care patients: a HamesNet Research Network study. J Am Board Fam Med. 2007;20(2):144–150....
2. Palmer JB, Drennan JC, Baba M. Evaluation and treatment of swallowing impairments. Am Fam Physician. 2000;61(8):2453–2462. Accessed May 2, 2020. https://www.aafp.org/afp/2000/0415/p2453.html
3. Sasegbon A, Hamdy S. The anatomy and physiology of normal and abnormal swallowing in oropharyngeal dysphagia. Neurogastroenterol Motil. 2017;29(11):e13100.
4. Shaw SM, Martino R. The normal swallow: muscular and neurophysiological control. Otolaryngol Clin North Am. 2013;46(6):937–956.
5. Cho SY, Choung RS, Saito YA, et al. Prevalence and risk factors for dysphagia: a USA community study. Neurogastroenterol Motil. 2015;27(2):212–219.
6. Traynor BJ, Codd MB, Corr B, et al. Clinical features of amyotrophic lateral sclerosis according to the El Escorial and Airlie House diagnostic criteria: a population-based study. Arch Neurol. 2000;57(8):1171–1176.
7. Scherer K, Bedlack RS, Simel DL. Does this patient have myasthenia gravis? JAMA. 2005;293(15):1906–1914.
8. Miarons Font M, Rofes Salsench L. Antipsychotic medication and oropharyngeal dysphagia: systematic review. Eur J Gastroenterol Hepatol. 2017;29(12):1332–1339.
9. Liu LWC, Andrews CN, Armstrong D, et al. Clinical practice guidelines for the assessment of uninvestigated esophageal dysphagia. J Can Assoc Gastroenterol. 2018;1(1):5–19.
10. Roden DF, Altman KW. Causes of dysphagia among different age groups: a systematic review of the literature. Otolaryngol Clin North Am. 2013;46(6):965–987.
11. Serra-Prat M, Hinojosa G, López D, et al. Prevalence of oropharyngeal dysphagia and impaired safety and efficacy of swallow in independently living older persons. J Am Geriatr Soc. 2011;59(1):186–187.
12. Lin LC, Wu SC, Chen HS, et al. Prevalence of impaired swallowing in institutionalized older people in Taiwan. J Am Geriatr Soc. 2002;50(6):1118–1123.
13. Spieker MR. Evaluating dysphagia. Am Fam Physician. 2000;61(12):3639–3648. Accessed May 4, 2020. https://www.aafp.org/afp/2000/0615/p3639.html
14. Jansson-Knodell CL, Codipilly DC, Leggett CL. Making dysphagia easier to swallow: a review for the practicing clinician. Mayo Clin Proc. 2017;92(6):965–972.
15. Kidambi T, Toto E, Ho N, et al. Temporal trends in the relative prevalence of dysphagia etiologies from 1999–2009. World J Gastroenterol. 2012;18(32):4335–4341.
16. Richter JE, Rubenstein JH. Presentation and epidemiology of gastroesophageal reflux disease. Gastroenterology. 2018;154(2):267–276.
17. Straumann A, Katzka DA. Diagnosis and treatment of eosinophilic esophagitis. Gastroenterology. 2018;154(2):346–359.
18. Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV. Gastroenterology. 2016;150(6):1262–1279.e2.
19. Aziz Q, Fass R, Gyawali CP, et al. Functional esophageal disorders. Gastroenterology. 2016;150(6):1368–1379.
20. Kraichely RE, Arora AS, Murray JA. Opiate-induced oesophageal dysmotility. Aliment Pharmacol Ther. 2010;31(5):601–606.
21. Ratuapli SK, Crowell MD, DiBaise JK, et al. Opioid-induced esophageal dysfunction (OIED) in patients on chronic opioids. Am J Gastroenterol. 2015;110(7):979–984.
22. Heijnen BJ, Speyer R, Bülow M, et al. ‘What about swallowing?’ Diagnostic performance of daily clinical practice compared with the Eating Assessment Tool-10. Dysphagia. 2016;31(2):214–222.
23. Lee BE, Kim GH. Globus pharyngeus: a review of its etiology, diagnosis and treatment. World J Gastroenterol. 2012;18(20):2462–2471.
24. Khalaf M, Chowdhary S, Elias PS, et al. Distal esophageal spasm: a review. Am J Med. 2018;131(9):1034–1040.
25. Rhatigan E, Tyrmpas I, Murray G, et al. Scoring system to identify patients at high risk of oesophageal cancer. Br J Surg. 2010;97(12):1831–1837.
26. Vakil N, Moayyedi P, Fennerty MB, et al. Limited value of alarm features in the diagnosis of upper gastrointestinal malignancy: systematic review and meta-analysis. Gastroenterology. 2006;131(2):390–401.
27. Moayyedi P, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia [published correction appears in Am J Gastroenterol. 2017;112(9):1484]. Am J Gastroenterol. 2017;112(7):988–1013.
28. Ashraf HH, Palmer J, Dalton HR, et al. Can patients determine the level of their dysphagia? World J Gastroenterol. 2017;23(6):1038–1043.
29. Varghese TK Jr, Hofstetter WL, Rizk NP, et al. The Society of Thoracic Surgeons guidelines on the diagnosis and staging of patients with esophageal cancer. Ann Thorac Surg. 2013;96(1):346–356.
30. Malagelada J, Bazzoli F, Boeckxstaens G, et al. World Gastroenterology Organisation global guidelines: dysphagia. Updated September 2014. Accessed March 17, 2020. https://www.worldgastroenterology.org/guidelines/global-guidelines/dysphagia/dysphagia-english
31. Acosta RD, Abraham NS, Chandrasekhara V, et al.; ASGE Standards of Practice Committee. The management of antithrombotic agents for patients undergoing GI endoscopy [published correction appears in Gastrointest Endosc. 2016;83(3):678]. Gastrointest Endosc. 2016;83(1):3–16.
32. McCormick SE, Kozarek RA. Endoscopic evaluation of esophageal motility disorders. GI Motility Online. 2006. Accessed March 17, 2020. https://www.nature.com/gimo/contents/pt1/full/gimo29.html
33. Kahrilas PJ, Bredenoord AJ, Fox M, et al.; International High Resolution Manometry Working Group. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 2015;27(2):160–174.
34. Almansa C, Heckman MG, DeVault KR, et al. Esophageal spasm: demographic, clinical, radiographic, and manometric features in 108 patients. Dis Esophagus. 2012;25(3):214–221.
35. Mion F, Marjoux S, Subtil F, et al. Botulinum toxin for the treatment of hypercontractile esophagus: results of a double-blind randomized sham-controlled study. Neurogastroenterol Motil. 2019;31(5):e13587.
36. Bredenoord AJ. Hypercontractile esophageal motility disorder or functional esophageal symptoms and unrelated hypercontractility? Neurogastroenterol Motil. 2019;31(5):e13594.
37. Zendehdel K, Nyrén O, Edberg A, et al. Risk of esophageal adenocarcinoma in achalasia patients, a retrospective cohort study in Sweden. Am J Gastroenterol. 2011;106(1):57–61.
38. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease [published correction appears in Am J Gastroenterol. 2013;108(10):1672]. Am J Gastroenterol. 2013;108(3):308–328.
39. Weijenborg PW, Cremonini F, Smout AJ, et al. PPI therapy is equally effective in well-defined non-erosive reflux disease and in reflux esophagitis: a meta-analysis. Neurogastroenterol Motil. 2012;24(8):747–757,e350.
40. Dellon ES, Katzka DA, Collins MH, et al.; MP-101-06 Investigators. Budesonide oral suspension improves symptomatic, endoscopic, and histologic parameters compared with placebo in patients with eosinophilic esophagitis. Gastroenterology. 2017;152(4):776–786.e5.
41. Lucendo AJ, Arias Á, González-Cervera J, et al. Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease. J Allergy Clin Immunol. 2013;131(3):797–804.
42. Ford AC, Luthra P, Tack J, et al. Efficacy of psychotropic drugs in functional dyspepsia: systematic review and meta-analysis. Gut. 2017;66(3):411–420.
43. Baijens LW, Clavé P, Cras P, et al. European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome. Clin Interv Aging. 2016;11:1403–1428.
44. Braun T, Juenemann M, Viard M, et al. What is the value of fibre-endoscopic evaluation of swallowing (FEES) in neurological patients? A cross-sectional hospital-based registry study. BMJ Open. 2018;8(3):e019016.
45. Alagiakrishnan K, Bhanji RA, Kurian M. Evaluation and management of oropharyngeal dysphagia in different types of dementia: a systematic review. Arch Gerontol Geriatr. 2013;56(1):1–9.
46. Brady S, Donzelli J. The modified barium swallow and the functional endoscopic evaluation of swallowing. Otolaryngol Clin North Am. 2013;46(6):1009–1022.
47. Belafsky PC, Mouadeb DA, Rees CJ, et al. Validity and reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol. 2008;117(12):919–924.
48. McHorney CA, Robbins J, Lomax K, et al. The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III. Documentation of reliability and validity Dysphagia. 2002;17(2):97–114.
49. Wallace KL, Middleton S, Cook IJ. Development and validation of a self-report symptom inventory to assess the severity of oral-pharyngeal dysphagia. Gastroenterology. 2000;118(4):678–687.
50. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009;(2):CD007209.
51. Teno JM, Gozalo PL, Mitchell SL, et al. Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc. 2012;60(10):1918–1921.
52. Lubart E, Leibovitz A, Dror Y, et al. Mortality after nasogastric tube feeding initiation in long-term care elderly with oropharyngeal dysphagia—the contribution of refeeding syndrome. Gerontology. 2009;55(4):393–397.
53. Givens JL, Selby K, Goldfeld KS, et al. Hospital transfers of nursing home residents with advanced dementia. J Am Geriatr Soc. 2012;60(5):905–909.
54. American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc. 2014;62(8):1590–1593.
55. L'Institut de Tourisme et d'Hotellerie du Quebec; Palliative Care McGill, Department of Family Medicine, McGill University; The International Congress on Palliative Care; et al. Eating well, always. 2019. Accessed March 17, 2020. https://www.mcgill.ca/palliativecare/files/palliativecare/pal2019_recipe_book_eng_final_0.pdf
56. Saconato M, Chiari BM, Lederman HM, et al. Effectiveness of chin-tuck maneuver to facilitate swallowing in neurologic dysphagia. Int Arch Otorhinolaryngol. 2016;20(1):13–17.
57. Vose A, Nonnenmacher J, Singer ML, et al. Dysphagia management in acute and sub-acute stroke. Curr Phys Med Rehabil Rep. 2014;2(4):197–206.
Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact firstname.lastname@example.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions