Dysphagia
| Luminal | Intrinsic narrowing | Extrinsic compression |
Large bolus Foreign body | Inflammatory condition causing edema and swelling Stomatitis Pharyngitis epiglottitis Esophagitis – Viral (herpes simplex, varicella-zoster, cytomegalovirus) – Bacterial – Fungal (candidal) – Mucocutaneous bullous diseases – Caustic, chemical, thermal injury Webs and rings Pharyngeal (Plummer-Vinson syndrome) Esophageal (congenital, inflammatory) Lower esophageal mucosal ring (Schatzki ring) Benign strictures Peptic Caustic and pill-induced Inflammatory (Crohn’s disease, candidal, mucocutaneous lesions) Ischemic Postoperative, post-irradiation Congenital Malignant tumors Primary carcinoma – Squamous cell carcinoma – Adenocarcinoma – Lymphoma / Melanoma – Kaposi’s sarcoma Metastatic carcinoma Benign tumors Leiomyoma Lipoma Angioma Inflammatory fibroid polyp Epithelial papilloma | Cervical spondylitis Vertebral osteophytes Retropharyngeal abscess and masses Enlarged thyroid gland Diverticula – Zenker diverticulum- above UES 🡪 due to disordered cricopharyngeal motor dysfunction – Traction diverticulum- midpoint 🡪 Scarring from mediastinal lymphadenitis; motor dysfunction; congenital – Epiphrenic diverticulum- above LES 🡪 Dyscoordination of peristalsis and LES relaxation. Vascular compression – Aberrant right subclavian artery – Right-sided aorta – Left atrial enlargement – Aortic aneurysm Posterior mediastinal masses – Pancreatic tumo – pancreatitis – Postvagotomy hematoma and fibrosis |
Neuromuscular causes
| Difficulty in initiating swallowing reflex | Paralysis of the tongue Oropharyngeal anesthesia Lack of saliva (e.g., Sjögren’s syndrome) Lesions of sensory components of vagus and glossopharyngeal nerves Lesions of swallowing center |
| Disorders of pharyngeal and esophageal striated muscle | Muscle weakness 1- Lower motor neuron lesion (bulbar paralysis) —- Cerebrovascular accident —- Motor neuron disease —- Poliomyelitis, postpolio syndrome —- Polyneuritis —- Amyotrophic lateral sclerosis —- Familial dysautonomia 2- Neuromuscular —- Myasthenia gravis 3- Muscle disorders —- Polymyositis —- Dermatomyositis —- Myopathies (myotonic dystrophy, oculopharyngeal myopathy) Nonperistaltic contractions or impaired deglutitive inhibition 1- Pharynx and upper esophagus —- Rabies —- Tetanus —- Extrapyramidal tract disease —- Upper motor neuron lesions (pseudobulbar paralysis) 2- Upper esophageal sphincter (UES) —- Paralysis of suprahyoid muscles (causes same as paralysis of pharyngeal musculature) —- Cricopharyngeal achalasia |
| Disorders of esophageal smooth muscle | Paralysis of esophageal body causing weak contractions – Scleroderma and related collagen-vascular diseases – Hollow visceral myopathy – Myotonic dystrophy – Metabolic neuromyopathy (amyloid, alcohol?, diabetes?) – Achalasia (classical) Nonperistaltic contractions or impaired deglutitive inhibition 1- Esophageal body —- Diffuse esophageal spasm —- Achalasia (vigorous) —- Variants of diffuse esophageal spasm 2- Lower esophageal sphincter —- Achalasia ——– Primary ——– Secondary ——– Chagas’ disease ——– Carcinoma ——– Lymphoma ——– Neuropathic intestinal pseudoobstruction syndrome ——– Toxins and drugs —- Lower esophageal muscular (contractile) ring |