Gastroenterology & Internal Medicine & Digestive Surgery
Esophageal dysphagia
Dysphagia is the subjective sensation of difficulty or discomfort during swallowing - the perception that food or liquids are not progressing normally from the mouth to the stomach. It is distinguished from odynophagia (pain on swallowing) and pharyngeal globus (persistent sensation of a foreign body in the throat without objective swallowing difficulty). Classically, we distinguish two main categories according to the anatomical level of the disorder: oropharyngeal dysphagia (high), linked to a disturbance of the oral or pharyngeal phases of swallowing (neurological, muscular, structural causes of the pharynx and aerodigestive carrefour) - discussed separately - and esophageal dysphagia (low), the subject of this data sheet, in which discomfort is felt in the chest or retrosternal region, typically starting 2 to 5 seconds after the initiation of swallowing. Esophageal dysphagia affects around 7-10 % of the adult population, and its prevalence increases with age (15-20 % of institutionalized elderly people); it represents a major cause of undernutrition, aspiration pneumonia and reduced quality of life. The diagnostic approach is based on a cardinal clinical element - the distinction between dysphagia to solids alone (suggestive of an obstructive mechanical cause) and dysphagia to solids and liquids from the outset (suggestive of a motor cause) - which guides the entire work-up. Any symptom of progressive dysphagia should be considered potentially malignant until proven otherwise, and warrants immediate oesogastroduodenal fibroscopy (EGDF).
Diagnostic approach - clinical key solids vs liquids
- Dysphagia to solids alone (liquids pass well) → mechanical (obstructive) cause to be investigated as a priority: peptic stenosis (chronic GERD with esophagitis and fibrosis), Schatzki's ring (mucosal ring esophageal-gastric junction), cancer of esophagus or esophageal-gastric junction, extrinsic compression (mediastinum), eosinophilic esophagitis (EO); progression of dysphagia to liquids indicates worsening obstruction or an associated motor component
- Dysphagia to solids and liquids from the outset → motor cause to be sought as a priority: achalasia (lack of relaxation of the lower esophageal sphincter - LES), diffuse esophageal spasm, pseudoachalasia (cardiac cancer or lymphoma compressing the myenteric plexus), scleroderma (esophageal atony), nutcracker esophagus
- Additional orienting clinical features: felt location of discomfort (high retrosternal → upper esophagus; epigastric → distal esophagus or cardia); regurgitation of undigested food (achalasia - late regurgitation of food ingested hours earlier; Zenker's diverticulum - regurgitation of undigested food immediately after meal) ; pyrosis and acid regurgitation (GERD → peptic stenosis, OE); rapid weight loss + progressive dysphagia (cancer until proven otherwise); otalgia (referred pain - pharyngolaryngeal or high oesophageal cancer); respiratory symptoms (nocturnal cough, recurrent pneumonia → achalasia with aspiration, oesotracheal fistula)
- Red flags - urgent consultation or FOGD within 2 weeks: progressive dysphagia (to solids then liquids); involuntary weight loss (>5 % of weight in 3 months); odynophagia (pain on swallowing - infectious oesophagitis, ulcer or cancer); haematemesis or melena (high digestive bleeding); palpable cervical or supra-clavicular adenopathies; age >50 years with de novo dysphagia; history of ENT or oesophageal cancer.
Causes of esophageal dysphagia
| Cause | Mechanism and clinical presentation | Diagnosis and treatment |
|---|---|---|
| Achalasia Most frequent motor cause |
Destruction of inhibitory neurons (VIP, NO) of Auerbach's myenteric plexus → absence of SOI relaxation and aperistalsis of esophageal body → food stasis; incidence 1-2/100,000/year - peak 25-60 years - gender equality; progressive dysphagia solids + liquids at onset, late regurgitation of undigested food (sometimes hours after meal), chest pain (especially vigorous achalasia - type II), progressive weight loss, paradoxical pyrosis (fermentative stasis); complications: recurrent aspiration pneumonia, esophageal cancer (risk ×10-15 - squamous cell carcinoma - in stasis-induced dilated esophagus) | High-resolution manometry (HRM) - gold standard - Chicago classification v4.0: type I (aperistalsis + absence of SOI relaxation); type II (pan-oesophageal pressurization - better post-treatment prognosis); type III (spastic achalasia); barium transit: «bird's beak» image at oeso-gastric junction; FOGD (exclude neoplastic pseudoachalasia - biopsies + EUS); treatment: laparoscopic Heller myotomy + partial fundoplicature (Dor) - success rate 80-90 %; POEM (Per-Oral Endoscopic Myotomy) - similar efficacy, less invasive, higher risk of post-procedure GERD; pneumatic dilatation (less invasive alternative - success 60-85 % - repeats required); botulinum toxin injection (temporary 6-12 months - elderly inoperable) |
| Peptic stenosis Complications of chronic GERD |
Uncontrolled or untreated GERD over many years → erosive esophagitis → scarring fibrosis → luminal narrowing of distal esophagus; progressive dysphagia to solids - liquids retained for long periods; history of old pyrosis and acid regurgitation often present; sometimes dysphagia is the first symptom (low-symptomatic GERD); risk of underlying Barrett's esophagus (intestinal metaplasia) - systematic screening at FOGD | FOGD - direct visualization of stenosis + biopsies (exclude underlying adenocarcinoma, Barrett's esophagus); treatment : endoscopic dilatation with bougies (Savary-Gilliard bouginage, Maloney dilators) or balloons - success 80-90 % - frequent recurrences if GERD uncontrolled; lifetime double-dose PPI (omeprazole 40 mg 2×/day or esomeprazole 40 mg 2×/day) after dilatation to prevent recurrence; surgery (fundoplicature) if refractory GERD with recurrent strictures |
| Esophageal cancer Absolute red flag |
Two main histological types: squamous cell carcinoma (middle and upper third - risk factors: tobacco, alcohol, low fruit/vegetable diet, achalasia, palmoplantar keratoderma - declining prevalence in the West) and adenocarcinoma (lower third and cardia - risk factors: chronic GERD, obesity, Barrett's esophagus - rising sharply in North America +600 % since 1970); rapid progressive dysphagia (solids → liquids → saliva within weeks to months) + marked weight loss + odynophagia + regurgitation; often late diagnosis (stage III-IV in 70-75 % of cases at time of diagnosis); 5-year overall survival: 15-20 % | Urgent FOGD + multiple biopsies (sensitivity 95-98 %); thoraco-abdomino-pelvic CT + PET-FDG (extension assessment - metastases); echo-endoscopy (EUS - local T and N staging - gold standard for parietal invasion); curative treatment : surgery (esophagectomy - Ivor Lewis or transhiatal) ± neoadjuvant chemoradiotherapy (CROSS protocol - cisplatin + paclitaxel + RT 41.4 Gy - improved survival) for resectable stages (T2-T3 N0-N1); palliative treatment : endoscopic prosthesis (esophageal stent - restores swallowing rapidly) + chemotherapy + immunotherapy (pembrolizumab - FDA 2019 approval for PD-L1 + adenocarcinoma - KEYNOTE-590) |
| Eosinophilic esophagitis (EO) | Chronic immune-mediated inflammatory disease - infiltration of esophageal mucosa by eosinophils (>15 eosinophils/field at ×400 magnification) in response to food allergens (cow's milk, wheat, egg, soy, peanut, seafood - the 6 major allergens); rapidly increasing prevalence: 1/2,000 adults in North America - peak in young (20-40 years) male adults (H:F 3:1); intermittent dysphagia to solids ± repeated food impaction; PPI-refractory pyrosis in young adults with atopy (asthma, rhinitis, eczema - 70 % of EOs have atopy); characteristic endoscopic appearance: concentric rings (tracheization), longitudinal furrows, whitish exudate, mucosal fragility (crepe paper) | FOGD + staged biopsies (proximal + distal esophagus - minimum 6 biopsies per site - density ≥15 eosinophils/HPF); pH-metry or 8-week PPI test (exclude GERD with secondary eosinophilia - OE must be PPI-nonresponder for diagnosis); treatment: food eviction (6-food elimination diet or allergy-test directed diet); swallowed fluticasone (spacerless spray - 440-880 µg 2×/day) or viscous oral budesonide (Jorveza - first treatment specifically approved in Europe); dupilumab (anti-IL-4Rα antibody - FDA/Health Canada 2022 approval for moderate to severe EO - PART 1/2 trials); endoscopic dilatation if fibrotic stenosis |
| Schatzki ring | Mucosal (or musculo-mucosal) ring located at the oeso-gastric junction, often associated with a hernial hiatus; intermittent, non-progressive dysphagia to solids (especially meat and bread) - steak house syndrome - often well tolerated for a long time as liquids pass well and solids can be regurgitated or dissolved; prevalence 6-14 % of barium swallows - largely underdiagnosed | Barium transit (best visualization if ring <13 mm with solid barium plug) or FOGD (if ring ≥12-13 mm can be seen - biopsies to exclude OE); treatment: single dilatation with balloon or candles - very effective - recurrences in 30-50 % - new single dilatation; PPI treatment if associated GERD. |
| Extrinsic compression | Dysphagia lusoria (aberrant right subclavian artery compressing esophagus from behind - congenital malformation); plunging thyroid goiter; mediastinal adenopathies (lymphoma, bronchial cancer, sarcoidosis); aortic aneurysm; post-traumatic mediastinal hematoma; mediastinal cyst | chest CT with contrast (visualization of compression) or mediastinal MRI; barium transit (image of extrinsic compression); treatment of underlying cause |
| Diffuse esophageal spasm / Hyperperistaltic esophagus | Primary motor disorders of the oesophagus - simultaneous or high-amplitude contractions in the body of the oesophagus; intermittent dysphagia to solids and liquids + intense chest pain that may mimic acute coronary syndrome (retrosternal pain radiating to the back, jaw, left arm); possible triggering by cold liquids, stress, spicy foods | High-resolution manometry (HRM) - Chicago classification: diffuse esophageal spasm (ICD >450 mmHg.s.cm with ≥20 % of premature contractions); hyperperistalsis/nutcracker esophagus (mean ICD >8,000 mmHg.s.cm); treatment: calcium-channel blockers (nifedipine, diltiazem); sublingual nitrates (acute chest pain); low-dose tricyclic antidepressants (imipramine 25-75 mg/night - viscerosensitivity modulators); botulinum toxin injection; POEM for refractory forms |
Complementary tests - diagnostic algorithm
- FOGD (fibroscopy of the oesophagus and duodenum) - first-line examination for all esophageal dysphagia: direct visualization of the mucosa + staged biopsies (stenosis, OE, Barrett's, cancer); allows immediate therapeutic dilatation; urgent indication if red flags (progressive dysphagia, weight loss, >50 years of age); usual preparation: 6-hour fasting + local pharyngeal anesthesia ± light sedation
- Esophageal barium transit: complements FOGD for functional and morphological assessment - visualizes bird's beak image of achalasia, Schatzki rings (best seen with solid barium plug), diverticula, extrinsic compression; less sensitive than FOGD for superficial lesions; useful if FOGD is normal and dysphagia persists
- High-resolution manometry (HRM) - gold standard for motor disorders: simultaneous measurement of pressures along the entire length of the esophagus (36 sensors spaced 1 cm apart); Chicago classification v4.0 (2021): major disorders (achalasia types I/II/III, esophageal junction obstruction - EGJOO); minor disorders (diffuse esophageal spasm, hyperperistaltic esophagus, ineffective peristalsis); reserved after normal FOGD for investigation of dysphagia without identified structural cause
- pH-metry and impedance-pH: measurement of esophageal acid exposure over 24-48h (ambulatory pH-metry) + detection of non-acid reflux (impedance); indicated prior to anti-reflux surgery, for evaluation of EO (exclusion of GERD), and in cases of PPI-refractory pyrosis
- Endoscopic ultrasound (EUS): local staging of esophageal cancers (T1-T4 parietal invasion and N adenopathies) + biopsy of mediastinal adenopathies; exclude neoplastic pseudoachalasia (thickening of the esophageal-gastric junction)
ℹ️
L'esophageal food impaction - complete blockage of food (often a piece of meat) in the esophageal lumen - is the most frequent acute complication of esophageal strictures and eosinophilic esophagitis. It manifests as sudden total dysphagia with hypersalivation, inability to swallow saliva and retrosternal pain. Attempting to pass the alimentary bolus by drinking water increases the risk of aspiration pneumonia. Persistent impaction lasting more than 6 hours requires emergency endoscopic extraction. Never administer IV glucagon (recent meta-analyses have shown no efficacy beyond placebo - Glucagon Esophageal Food Impaction Trial).
Signs requiring urgent consultation or 911
Go to the emergency room immediately if you have any of the following symptoms complete food impaction (total inability to swallow, even saliva - hypersalivation - intense retrosternal pain) - emergency endoscopic extraction required within 6 hours to avoid perforation and aspiration pneumonia.
Consult your doctor or go to the emergency room immediately if you experience progressive dysphagia (first with solids, then with liquids over a few weeks), involuntary weight loss associated with dysphagia, odynophagia (pain on swallowing), blood in vomit or stools (hematemesis, melena) - these symptoms should lead to an upper gastrointestinal fibroscopy within 2 weeks.
Consult at Clinique Omicron
Clinique Omicron's physicians assess patients presenting with dysphagia, refer for upper GI fibroscopy and high-resolution manometry depending on the clinical presentation, prescribe the appropriate biological work-up, initiate treatment of common causes (GERD with peptic stenosis, eosinophilic esophagitis) and ensure post-dilatation follow-up. Red flags (progressive dysphagia, weight loss, age >50) are treated as a priority, with rapid referral to gastroenterology. Consultations are available at our points of service in Quebec, as well as via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The contents of this page are provided for information purposes only and do not replace the advice of a qualified healthcare professional. Any progressive dysphagia or dysphagia associated with weight loss should be considered as potentially malignant and warrants a digestive fibroscopy without delay.
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