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Official reprint from UpToDate®

www.uptodate.com © 2022 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Approach to the evaluation of dysphagia in adults

Author: Ronnie Fass, MD
Section Editor: Mark Feldman, MD, MACP, AGAF, FACG
Deputy Editor: Kristen M Robson, MD, MBA, FACG

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: May 2022. | This topic last updated: Mar 30, 2022.

INTRODUCTION

Dysphagia is an alarm symptom that warrants prompt evaluation to define the exact cause and
initiate appropriate therapy. It may be due to a structural or motility abnormality in the passage
of solids or liquids from the oral cavity to the stomach. Patients' complaints range from the
inability to initiate a swallow to the sensation of solids or liquids being hindered during their
passage through the esophagus into the stomach.

This topic will review the evaluation of patients with dysphagia and diagnostic testing in
patients with esophageal dysphagia. Our recommendations are largely consistent with
guidelines developed by several professional societies [1-4].

The pathogenesis, diagnosis, and evaluation of patients with oropharyngeal dysphagia are
discussed separately. (See "Oropharyngeal dysphagia: Etiology and pathogenesis" and
"Oropharyngeal dysphagia: Clinical features, diagnosis, and management".)

DEFINITIONS

The terms dysphagia, odynophagia, and globus are defined as follows:

● Dysphagia is a subjective sensation of difficulty or abnormality of swallowing.

● Odynophagia is pain with swallowing.

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● Globus sensation is a nonpainful sensation of a lump, tightness, foreign body or retained

food bolus in the pharyngeal or cervical area [5]. Globus, on the other hand, is a functional
esophageal disorder that is characterized by globus sensation but without an underlying
structural abnormality, gastroesophageal reflux disease, or a major esophageal motility
disorder [6]. (See "Globus sensation".)

AGE OF ONSET

Dysphagia in older adults should not be attributed to normal aging. Aging alone causes mild
esophageal motility abnormalities, which are rarely symptomatic [7].

ACUTE DYSPHAGIA

The acute onset of inability to swallow solids and/or liquids, including secretions, suggests
impaction of a foreign body in the esophagus and requires immediate attention.

Food impaction is the most common cause for acute onset of dysphagia in adults. (See
"Ingested foreign bodies and food impactions in adults".)

Incidence and epidemiology — The estimated annual incidence of esophageal food impaction
is 25 per 100,000 persons per year and with a higher incidence in males compared with females
(1.5:1) [8,9]. The incidence increases with age, especially after the seventh decade.

Clinical presentation — Patients usually develop symptoms after ingesting meat (most
commonly beef, chicken, and turkey), which completely obstructs the esophageal lumen,
resulting in expectoration of saliva.

Management — Administration of glucagon intravenously can be initially attempted to relax

the lower esophageal sphincter and promote passage of the food bolus [10]. The food
impaction can be removed during upper endoscopy using grasping devices (either en bloc or
piecemeal, depending upon the consistency of the bolus), or it can be gently pushed into the
stomach using an endoscope [8,11]. Management of food impaction is discussed in detail
separately. (See "Ingested foreign bodies and food impactions in adults", section on 'Food
bolus'.)

EVALUATION OF NONACUTE DYSPHAGIA

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Distinguishing oropharyngeal from esophageal dysphagia — The first step in evaluating

patients with nonacute dysphagia is to determine if the symptoms are due to oropharyngeal or
esophageal dysphagia based on the patient's answers to the questions in the following table (
table 1) [12]:

● Oropharyngeal dysphagia – Oropharyngeal or transfer dysphagia is characterized by

these features:

• Patients have difficulty initiating a swallow.

• Patients may point toward the cervical region as the site of their symptoms.

• Swallowing may be accompanied by nasopharyngeal regurgitation, aspiration, and a

sensation of residual food remaining in the pharynx.

• Oral dysfunction can lead to drooling, food spillage, sialorrhea, piecemeal swallows,
and dysarthria.

• Pharyngeal dysfunction can lead to coughing or choking during food consumption,

and dysphonia.

The evaluation of patients with oropharyngeal dysphagia is discussed in detail separately (

table 2). (See "Oropharyngeal dysphagia: Etiology and pathogenesis" and
"Oropharyngeal dysphagia: Clinical features, diagnosis, and management".)

● Esophageal dysphagia – Patients with esophageal dysphagia commonly report the

following:

• Difficulty swallowing several seconds after initiating a swallow, and

• A sensation that foods and/or liquids are being obstructed in their passage from the
upper esophagus to the stomach.

Patients may point to the suprasternal notch or to an area behind the sternum as the site
of obstruction. While retrosternal dysphagia usually corresponds with the location of the
lesion, suprasternal dysphagia is commonly referred from below [13]. Esophageal
dysphagia arises within the body of the esophagus, the lower esophageal sphincter, or
cardia. A large number of conditions are associated with esophageal dysphagia ( table 3
).

Characterizing the symptoms — Dysphagia should be characterized according to types of

food that produce symptoms, the time course (ie, progressive or intermittent), severity, and
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associated symptoms ( algorithm 1):

● Solid, liquid, or both? – A critical component of the medical history is determining the
types of food that produce symptoms (ie, solids, liquids, or both). Dysphagia to both solids
and liquids from the onset of symptoms is probably due to a motility disorder of the
esophagus. Dysphagia to solids only is usually present when the esophageal lumen is
narrowed to 13 mm or less (eg, by a stricture).

● Progressive or intermittent? – It is important to ask if the symptoms are intermittent or

are gradually progressive. Progressive dysphagia, beginning with dysphagia to solids
followed by dysphagia to liquids, is usually caused by a peptic stricture or obstructing
lesion [14]. Symptoms of peptic stricture are slowly and gradually progressive, whereas
those due to a malignancy progress more rapidly [15].

Intermittent dysphagia may be related to a lower esophageal ring or web. Patients with
motility disorders may also exhibit progressive dysphagia (eg, achalasia) or may exhibit
intermittent or nonprogressive dysphagia (eg, distal esophageal spasm).

Psychologic factors may influence the expression and severity of dysphagia symptoms. In
a study including 236 patients with dysphagia who completed psychologic and symptom-
based questionnaires and were evaluated with esophageal manometry, esophageal
hypervigilance and visceral anxiety were the strongest predictors of dysphagia severity
(eg, number of food impactions or emergency department visits) [16]. The correlation was
observed in patients with and without major esophageal motility disorders (eg, achalasia).
While psychologic factors have been identified as predictors of disease severity for
patients with other gastrointestinal disorders (eg, gastroesophageal reflux disease,
irritable bowel syndrome), this study has suggested that anxiety and hypervigilance may
also contribute to dysphagia severity [6,17,18]. (See "Pathophysiology of irritable bowel
syndrome", section on 'Psychosocial dysfunction'.)

Associated symptoms — Associated symptoms or findings can help to narrow the differential
diagnosis. These may include:

● Heartburn
● Weight loss
● Hematemesis
● Anemia
● Regurgitation of food particles, and
● Respiratory symptoms

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As an example, chronic heartburn in a patient with dysphagia may be a clue to complications of

gastroesophageal reflux disease, such as erosive esophagitis, peptic stricture, or
adenocarcinoma of the esophagus. Patients with peptic stricture usually have a history of
heartburn and regurgitation but no weight loss, while patients with esophageal cancer tend to
be older males with significant weight loss [2]. (See "Complications of gastroesophageal reflux
in adults".)

SYMPTOM-BASED DIFFERENTIAL DIAGNOSIS

Solids only with progressive symptoms

Esophageal stricture — Dysphagia to solids that is only gradually progressive is suggestive of

an esophageal stricture, which may be related to acid reflux, radiation therapy, or eosinophilic
esophagus.

Peptic stricture — Peptic stricture is a complication of gastroesophageal reflux disease

(GERD) and results from the healing process of erosive esophagitis. This benign esophageal
stricture is usually found in close proximity to the esophagogastric junction. The development
of peptic stricture among patients with reflux has been associated with older age, male sex, and
longer duration of reflux symptoms [19]. Peptic strictures have been observed in a number of
other conditions that lead to increased esophageal acid exposure (eg, systemic sclerosis,
Zollinger-Ellison syndrome, nasogastric tube placement, and after Heller myotomy or peroral
esophageal myotomy for achalasia). The management of benign esophageal strictures is
discussed separately. (See "Endoscopic interventions for nonmalignant esophageal strictures in
adults".)

Less common causes of stricture — Patients undergoing radiation therapy for thoracic
or head and neck tumors are at risk for developing esophagitis and esophageal strictures. In
the acute setting, patients may develop esophagitis resulting in dysphagia and odynophagia. In
some patients, chronic ischemia and fibrosis lead to chronic radiation esophagitis, which may
present as esophageal ulcerations or strictures in the proximal esophagus [20]. (See "Overview
of gastrointestinal toxicity of radiation therapy", section on 'Esophagitis'.)

Benign esophageal strictures may also be related to caustic ingestions, postsurgical resection
for esophageal or laryngeal cancer, drug-induced stricture, or eosinophilic esophagitis. (See
'Eosinophilic esophagitis' below and "Caustic esophageal injury in adults", section on
'Esophageal strictures'.)

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Carcinoma — Cancer of the esophagus or gastric cardia is associated with rapidly progressive
dysphagia, initially for solids and later for liquids. In addition, patients may have chest pain,
odynophagia, anemia, anorexia, and significant weight loss.

An achalasia-like syndrome (pseudoachalasia) has been described in patients with

adenocarcinoma of the cardia due to microscopic infiltration of the myenteric plexus or the
vagus nerve [21]. Certain features increase the likelihood that a patient has pseudoachalasia
due to malignancy [22]. These include short duration of symptoms (ie, less than six months),
presentation after age 60, excessive weight loss in relation to the duration of symptoms, and
difficult passage of the endoscope through the gastroesophageal junction. In such cases,
endoscopic ultrasonography with fine-needle aspiration (EUS-FNA) should be performed to
diagnose an underlying malignancy. (See "Achalasia: Pathogenesis, clinical manifestations, and
diagnosis" and "Epidemiology and pathobiology of esophageal cancer".)

Solids only with intermittent symptoms — Dysphagia to solid foods only that is intermittent
in nature may be caused by eosinophilic esophagitis, esophageal ring or web, or a vascular
anomaly.

Eosinophilic esophagitis — Up to 15 percent of patients being evaluated for dysphagia with

endoscopy are found to have eosinophilic esophagitis [23-25]. Endoscopic findings associated
with eosinophilic esophagitis include:

● Stacked circular rings ("feline" esophagus) ( picture 1)

● Strictures (particularly proximal strictures) ( image 1)
● Linear furrows
● Whitish papules ( picture 1) (representing eosinophil microabscesses)
● Small caliber esophagus (see "Clinical manifestations and diagnosis of eosinophilic
esophagitis (EoE)", section on 'Endoscopy')

Individual endoscopic features suggestive of eosinophilic esophagitis have low sensitivity

ranging from 15 to 48 percent but high specificity ranging from 90 to 95 percent [26]. The
diagnosis of eosinophilic esophagitis is established by upper endoscopy and esophageal biopsy,
which demonstrates an increased number of eosinophils (>15 per high power field). (See
"Clinical manifestations and diagnosis of eosinophilic esophagitis (EoE)", section on 'Histology'.)

Esophageal webs and rings — Patients with esophageal rings and webs have intermittent
dysphagia for solids. Esophageal rings have been described in association with iron deficiency
(ie, the Plummer-Vinson or Patterson-Kelly syndrome) in which case anemia, koilonychia, or
other manifestations of iron deficiency may be present ( image 2) [27]. (See "Causes and

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diagnosis of iron deficiency and iron deficiency anemia in adults", section on 'Clinical
manifestations'.)

A detailed discussion of esophageal rings and webs is presented separately. (See "Esophageal
rings and webs".)

Esophageal webs and rings can partially or completely compromise the esophageal lumen [28].
They can be solitary or multiple.

● An esophageal web is a thin mucosal fold that protrudes into the esophageal lumen and is
covered with squamous epithelium. Webs most commonly occur anteriorly in the cervical
esophagus, causing focal narrowing in the postcricoid area ( image 3).

● Esophageal rings are typically mucosal structures but in rare cases are muscular. Rings are
found at the gastroesophageal junction, are smooth, thin (<4 mm in axial length), and
covered with squamous mucosa above and columnar epithelium below ( picture 2 and
image 4) [29].

An esophageal web/ring is diagnosed on barium esophagram and/or upper endoscopy and

appears as a focal, thick constriction of variable luminal diameter [30]. Rings are usually found
at or a few centimeters above the squamocolumnar junction. Endoscopy is less sensitive than
the barium esophagram in detecting esophageal rings and a ring may be missed unless the
lower esophagus is widely distended [31].

Cardiovascular abnormalities — Vascular anomalies can cause dysphagia by compressing

the esophagus but are rare [32]. Some of the aberrant vessels form complete rings, while
others form incomplete rings around the esophagus [33]. (See "Vascular rings and slings".)

● Complete vascular ring anomalies include a double aortic arch, right aortic arch with
retroesophageal left subclavian artery and left ligamentum arteriosum, and right aortic
arch with mirror-image branching and left ligamentum arteriosum [33]. Dysphagia lusoria
is rare and is due to an aberrant right subclavian artery that passes dorsally between the
esophagus and the spine [32,34]. Extrinsic compression of the esophagus may be noted
on barium esophagram, and the diagnosis can be established by endoscopic
ultrasonography or computed tomography (CT) scan.

● In older adults, severe atherosclerosis or a large aneurysm of the thoracic aorta can result
in impingement on the esophagus and produce dysphagia ("dysphagia aortica").

When due to congenital causes, symptoms usually develop during childhood, but they may also
develop in adults. Most patients with an aberrant subclavian artery are symptom-free
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throughout their lives [35]. However, coughing, dysphagia, thoracic pain, or even Horner's
syndrome may develop at an older age [36]. If symptoms are intractable, surgical intervention
may be necessary. (See "Vascular rings and slings", section on 'Treatment'.)

Liquid and/or solid dysphagia — Dysphagia to liquids alone or to solids and liquids may be
related to either an esophageal motility disorder such as achalasia, distal esophageal spasm or
hypercontractile esophagus or to a functional disorder.

Achalasia — Primary achalasia is a disease of unknown etiology in which there is a loss of

normal peristalsis in the distal esophagus and a failure of lower esophageal sphincter (LES)
relaxation with swallowing.

Achalasia is an uncommon disorder that can occur at any age but is usually diagnosed in
patients between 25 and 60 years. Men and women are affected with equal frequency.
Progressively worsening dysphagia for solids (91 percent) and liquids (85 percent) and
regurgitation of bland, undigested food or saliva are the most frequent symptoms in patients
with achalasia. Other symptoms include chest pain, heartburn, and difficulty belching.

Barium esophagram and upper endoscopy are complementary tests to manometry in the
diagnosis of achalasia [37]. Findings on barium esophagram that are suggestive of achalasia
include a dilated esophagus that terminates in a beak-like narrowing (ie, "bird-beak"
appearance), aperistalsis, and poor emptying of barium from the esophagus ( image 5 and
image 6). However, barium esophagram may be nondiagnostic in up to one-third of patients
[38].

Upper endoscopy is performed to exclude pseudoachalasia, and those patients without

evidence of mechanical obstruction can then undergo esophageal manometry to confirm the
diagnosis. Lack of normal peristalsis in the distal two-thirds of the esophagus and incomplete
LES relaxation on esophageal manometry are characteristic of achalasia. (See "Achalasia:
Pathogenesis, clinical manifestations, and diagnosis".)

Other motility disorders — If upper endoscopy with esophageal biopsies is normal in a

patient with dysphagia to solids and/or liquids, further evaluation with esophageal manometry
and/or barium esophagram should be obtained (see "High resolution manometry"):

● Hypertensive or spastic motility disorders: Esophageal manometry is obtained to

establish the diagnosis of a spastic esophageal motility disorder. The specific manometric
criteria to diagnose distal esophageal spasm and hypercontractile esophagus are
discussed separately. (See "Major disorders of esophageal hyperperistalsis: Clinical
features, diagnosis and management".)
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Distal esophageal spasm (DES) and hypercontractile (jackhammer) esophagus can cause
intermittent, nonprogressive dysphagia to solids and liquids. Patients may also report
associated chest pain [39]. In patients with DES, the barium esophagram may show severe
nonperistaltic contractions, which may produce striking abnormalities in the barium
column. These findings have resulted in descriptions such as "rosary bead" or "corkscrew"
esophagus ( image 7 and image 8). However, radiographic studies may be normal
among patients with DES or be abnormal in patients with normal manometry testing; as a
result, barium esophagram is neither sensitive nor specific in this setting.

● Esophagogastric junction (EGJ) outflow obstruction: This disorder is defined as failure

or incomplete opening of the esophagogastric junction with normal, hypercontractile, or
hypocontractile peristalsis. The underlying cause may be incompletely expressed achalasia
or mechanical obstruction, and symptoms include continuous or intermittent dysphagia
for solids and liquids.

● Ineffective esophageal motility: By high-resolution esophageal manometry, ineffective

motility is defined as 50 to 90 percent of the liquid swallows being weak or failed. The
manometric diagnosis of ineffective esophageal motility does not always correlate with
symptoms or impaired esophageal function. In one study, only 30 percent of patients with
ineffective esophageal motility reported dysphagia. Moreover, studies using esophageal
intraluminal impedance testing have shown that up to 68 percent of liquid and 59 percent
of viscous swallows in such patients showed normal bolus transit [40].

● Absent contractility: High-resolution manometry may demonstrate a lack of esophageal

body peristalsis (ie, 100 percent failed swallows), which may be idiopathic or can be seen
in patients with systemic disorders (eg, systemic sclerosis or mixed connected tissue
syndrome). Absent contractility can lead to persistent or intermittent dysphagia for both
solids and liquids. (See 'Systemic sclerosis (scleroderma)' below.)

Systemic sclerosis (scleroderma) — Patients with systemic sclerosis often have a history of
heartburn and progressive dysphagia to both solids and liquids secondary to the underlying
motility abnormality or the presence of erosive esophagitis complicated by peptic stricture,
which may occur in up to 50 percent of these patients [41]. The diagnosis of systemic sclerosis is
suggested by the presence of skin thickening and hardening (sclerosis) that is not confined to
one area (ie, not localized scleroderma). The diagnosis is supported by the presence of
extracutaneous features and characteristic serum autoantibodies. Endoscopy may show erosive
esophagitis or a peptic stricture resulting from acid reflux. (See 'Esophageal stricture' above and
"Clinical manifestations and diagnosis of systemic sclerosis (scleroderma) in adults", section on

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'Evaluation for suspected systemic sclerosis' and "High resolution manometry", section on
'Absent contractility'.)

Esophageal involvement is present in up to 90 percent of patients with systemic sclerosis

[42,43]. Scleroderma primarily involves the smooth muscle layer of the gut wall, resulting in
atrophy and sclerosis of the distal two-thirds of the esophagus [42]. Absent peristalsis in the
distal two-thirds of the esophagus and poor bolus transit may be seen on esophageal
manometry and impedance, as well as low or absent lower esophageal sphincter pressure [44].
The proximal esophagus (striated muscle) is spared and exhibits normal motility. (See
"Gastrointestinal manifestations of systemic sclerosis (scleroderma)" and "High resolution
manometry", section on 'Absent contractility'.)

Functional dysphagia — According to the Rome IV criteria, functional dysphagia is defined by

the following:

● A sense of solid and/or liquid food lodging, sticking, or passing abnormally through the
esophagus.

● No evidence that an esophageal mucosal or structural abnormality is the cause of the

symptom.

● No evidence that GERD or eosinophilic esophagitis is the cause of the symptom.

● Absence of a major esophageal motor disorder (achalasia, esophagogastric junction

outflow obstruction, distal esophageal spasm, hypercontractile esophagus, and absent
peristalsis) [6].

All criteria must be fulfilled for the past three months with symptom onset at least six months
prior to the diagnosis and with a frequency of at least once a week.

Symptoms of dysphagia may be intermittent or present after each meal. Patients should be
reassured and instructed to avoid precipitating factors and chew well. In our experience,
symptoms may improve with time. In patients with severe symptoms, despite these measures,
a trial of a smooth muscle relaxant, such as a calcium channel blocker or tricyclic
antidepressant, can be offered. This approach is similar to the initial treatment of distal
esophageal spasm, which is discussed separately. (See "Major disorders of esophageal
hyperperistalsis: Clinical features, diagnosis and management", section on 'Management'.)

Empiric dilation with a mechanical (push-type or Bougie) dilator can be offered, but symptom
response is variable. (See "Endoscopic interventions for nonmalignant esophageal strictures in
adults".)
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Odynophagia and dysphagia — Both infectious esophagitis and medication-induced

esophagitis commonly present with dysphagia accompanied by painful swallowing.

Infectious esophagitis — Patients with infectious esophagitis, especially due to herpes

simplex virus, usually present with odynophagia and/or dysphagia [45,46]. Other causes of
infectious esophagitis include cytomegalovirus and Candida species. Although Candida species
are the most common fungal cause of esophagitis, other fungal infections including
cryptococcosis, histoplasmosis, blastomycosis, and aspergillosis have rarely been described
[47]. Other pathogens, such as mycobacteria, occasionally cause esophagitis in
immunosuppressed patients [48]. (See "Herpes simplex virus infection of the esophagus" and
"Esophageal candidiasis in adults", section on 'Epidemiology'.)

Medication-induced esophagitis — Medications in pill form may become lodged in the

esophagus for a prolonged period and then cause direct esophageal mucosal injury. Symptoms
may include dysphagia, odynophagia, and/or retrosternal pain. Patients often have a history of
swallowing a pill without water, commonly at bedtime. The diagnosis and management of
medication-induced esophagitis is discussed separately. (See "Pill esophagitis".)

Less common causes — Dysphagia and painful swallowing may be reported by patients with
reflux esophagitis or esophageal Crohn disease [49].

OTHER CAUSES OF NONSPECIFIC DYSPHAGIA

Lymphocytic esophagitis — Lymphocytic esophagitis is characterized by the presence of a

dense peripapillary lymphocytic infiltrate and peripapillary spongiosis involving the lower two-
thirds of the esophageal epithelium and the absence of significant neutrophilic or eosinophilic
infiltrates [50]. While lymphocytic esophagitis is being increasingly recognized on
histopathology in adults and has been associated with dysphagia, it is unclear if it is a distinct
clinical entity and its etiology is unknown [51-53].

In one retrospective study of 129,252 adults who had undergone an upper endoscopy, 0.1
percent had lymphocytic esophagitis on biopsy [51]. As compared with patients with normal
esophageal biopsies, patients with lymphocytic esophagitis were significantly more likely to be
older (63 versus 55 years) and to have presented with dysphagia (53 versus 33 percent), and
were significantly less likely to have gastroesophageal reflux disease (GERD; 19 versus 38
percent).

Sjögren's syndrome — Approximately three-quarters of patients with Sjögren's syndrome have

associated dysphagia [54,55]. Defective peristalsis has been demonstrated in one-third or more
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of patients with primary Sjögren's syndrome [56]. Xerostomia appears to exacerbate swallowing
discomfort but does not appear to correlate with dysphagia [54]. The diagnosis of Sjögren's
syndrome is discussed separately.

● (See "Clinical manifestations of Sjögren's syndrome: Exocrine gland disease".)

● (See "Clinical manifestations of Sjögren's syndrome: Extraglandular disease", section on
'Gastrointestinal tract'.)
● (See "Diagnosis and classification of Sjögren's syndrome", section on 'Diagnosis'.)

APPROACH TO DIAGNOSTIC TESTING

The approach to diagnostic testing to determine the etiology of esophageal dysphagia is based
upon the medical history ( algorithm 2).

Pre-endoscopy barium esophagram — We perform a barium contrast esophagram (barium

swallow) as the initial test (prior to upper endoscopy) in patients with the following:

● History/clinical features of proximal esophageal lesion (eg, surgery for laryngeal or

esophageal cancer, Zenker's diverticulum, or radiation therapy).

● Known complex (tortuous) stricture (eg, postcaustic injury or radiation therapy) [1].

In these patients, the blind intubation of the proximal esophagus during upper endoscopy
may be associated with the risk of perforation due to upper esophageal pathology.
However, it is important to note that performing a barium esophagram prior to an upper
endoscopy in such patients has not been demonstrated to decrease the rate of endoscopic
complications or improve outcomes [57].

Delayed esophageal clearance of barium in patients over 90 years old was originally referred to
as "presbyesophagus"; however, we avoid this term because it might imply that changes in
esophageal motility are a normal consequence of aging and do not require further evaluation
[58].

Method — Patients should be instructed to drink barium in the prone-oblique position;

maximal distension of the esophagogastric junction is achieved by having the patient swallow
barium rapidly in association with a variety of respiratory maneuvers [59]. In addition, asking
the patient to swallow 13 mm barium tablets or a solid bolus, such as a marshmallow or bread,
may be helpful for demonstrating subtle lesions in patients with persistent or intermittent solid
food dysphagia [60,61]. A timed barium esophagram is useful for evaluating achalasia before
and after treatment [2].
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Upper endoscopy — Patients with esophageal dysphagia should be referred for an upper
endoscopy to determine the underlying cause, exclude malignancy, and perform therapy (eg,
dilation of an esophageal ring) if needed [3,62]. (See "Overview of upper gastrointestinal
endoscopy (esophagogastroduodenoscopy)".)

In a study of over 1600 patients with dysphagia who underwent upper endoscopy, the
diagnostic yield was 54 percent and risk factors for having major pathology included male sex,
heartburn, and odynophagia [62].

Postendoscopy barium esophagram — We obtain a barium esophagram after a negative

upper endoscopy in patients in whom a mechanical obstruction is still suspected, as lower
esophageal rings or extrinsic esophageal compression can be missed by an upper endoscopy
[63]. The test is enhanced by the use of a barium tablet.

Esophageal manometry — Esophageal manometry should be performed in patients with

dysphagia in whom upper endoscopy is unrevealing and/or an esophageal motility disorder is
suspected. Although certain motility disorders (eg, achalasia) can be strongly suspected based
upon their characteristic radiographic appearance when in advanced stages ( image 6 and
image 5), confirmation with an esophageal manometry study is required to establish the
diagnosis [1,63].

The Chicago classification diagnostic algorithm categorizes the esophageal motility disorders
such as achalasia and distal esophageal spasm. The diagnosis of achalasia, gastrointestinal
motility testing, and high resolution esophageal manometry are discussed separately:

● (See "Overview of gastrointestinal motility testing".)

● (See "High resolution manometry".)
● (See "Achalasia: Pathogenesis, clinical manifestations, and diagnosis".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Dysphagia".)

INFORMATION FOR PATIENTS

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reading level, and they answer the four or five key questions a patient might have about a given
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or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Dysphagia (The Basics)" and "Patient education:
Upper endoscopy (The Basics)" and "Patient education: Esophageal stricture (The Basics)")

● Beyond the Basics topics (see "Patient education: Upper endoscopy (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Definitions – The terms dysphagia and odynophagia are defined as follows (see
'Definitions' above):

• Dysphagia is a subjective sensation of difficulty or abnormality of swallowing.

• Odynophagia is pain with swallowing.

● Acute dysphagia – The acute onset of inability to swallow solids and/or liquids, including
secretions, suggests impaction of a foreign body in the esophagus and requires
immediate attention. Food impaction is the most common cause for acute onset of
dysphagia in adults. (See 'Acute dysphagia' above.)

● Nonacute dysphagia – Dysphagia can be classified as oropharyngeal dysphagia or

esophageal dysphagia. Oropharyngeal or transfer dysphagia is characterized by difficulty
initiating a swallow. Swallowing may be accompanied by coughing, choking,
nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in
the pharynx. Esophageal dysphagia is characterized by difficulty swallowing several
seconds after initiating a swallow and a sensation of food getting stuck in the esophagus.
(See 'Evaluation of nonacute dysphagia' above.)

Esophageal dysphagia should be characterized according to types of food that produce

symptoms (ie, solids, liquids or both), the time course (ie, progressive or intermittent),
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severity, and associated symptoms (ie, weight loss, heartburn, or regurgitation) (

algorithm 1). (See 'Characterizing the symptoms' above.)

● Diagnostic evaluation – The approach to diagnostic testing to determine the cause of

esophageal dysphagia is based upon the medical history ( algorithm 2):

• Barium esophagram – We perform a barium contrast esophagram as the initial test

(prior to upper endoscopy) in patients with the following (see 'Pre-endoscopy barium
esophagram' above):

- History/clinical features of proximal esophageal lesion (eg, surgery for laryngeal or

esophageal cancer, Zenker's diverticulum, or radiation therapy).

- Known complex (tortuous) stricture (eg, postcaustic injury or radiation therapy).

• Upper endoscopy – Patients with esophageal dysphagia should be referred for an

upper endoscopy to determine the underlying cause, exclude malignancy, and perform
therapy (eg, dilation of an esophageal ring) if needed. (See 'Upper endoscopy' above.)

• Esophageal manometry – Esophageal manometry should be performed in patients

with dysphagia in whom upper endoscopy is unrevealing and/or an esophageal
motility disorder is suspected. Although certain motility disorders (eg, achalasia) can be
strongly suspected based upon their characteristic radiographic appearance when in
advanced stages, confirmation with an esophageal manometry study is required to
establish the diagnosis. (See 'Esophageal manometry' above.)

Use of UpToDate is subject to the Terms of Use.

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39. Clouse RE. Spastic disorders of the esophagus. Gastroenterologist 1997; 5:112.
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46. Généreau T, Lortholary O, Bouchaud O, et al. Herpes simplex esophagitis in patients with
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51. Haque S, Genta RM. Lymphocytic oesophagitis: clinicopathological aspects of an emerging

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53. Cohen S, Saxena A, Waljee AK, et al. Lymphocytic esophagitis: a diagnosis of increasing
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Sjögren's syndrome: correlation with dysphagia and xerostomia. Dig Dis Sci 1997; 42:113.
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in Sjögren's syndrome. Dig Dis Sci 1986; 31:225.
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58. SOERGEL KH, ZBORALSKE FF, AMBERG JR. PRESBYESOPHAGUS: ESOPHAGEAL MOTILITY IN
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59. Chen YM, Ott DJ, Gelfand DW, Munitz HA. Multiphasic examination of the esophagogastric
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GRAPHICS

Questions to ask patients with dysphagia

Do you have problems initiating a swallow or do you feel food getting stuck a few seconds after
swallowing? (Helps distinguish oropharyngeal from esophageal dysphagia.)

Do you cough or choke or is food coming back through your nose after swallowing? (Coughing,
choking, or nasal regurgitation suggests aspiration and oropharyngeal dysphagia.)

Do you have problem swallowing solids, liquids, or both? (Liquids, not solids, suggests a motility
disorder; solids progressing to liquids suggests a benign or malignant obstruction.)

How long have you had problems swallowing and have your symptoms progressed, remained stable,
or are they intermittent? (Rapidly progressive dysphagia is concerning for malignancy.)

Could you point to where you feel food is getting stuck? (Ability to localize source of dysphagia is
unreliable; best with oropharyngeal dysphagia.)

Do you have other symptoms such as loss of appetite, weight loss, nausea, vomiting, regurgitation of
food particles, heartburn, vomiting fresh or old blood, pain during swallowing, or chest pain?

Do you have medical problems such as diabetes mellitus, scleroderma, Sjögren's syndrome, overlap
syndrome, AIDS, neuromuscular disorders (stroke, Parkinson's, myasthenia gravis, muscular
dystrophy, multiple sclerosis), cancer, Chagas' disease or others?

Have you had surgery on your larynx, esophagus, stomach, or spine?

Have you received radiation therapy in the past?

What medications are you using now (ask specifically about potassium chloride, alendronate, ferrous
sulfate, quinidine, ascorbic acid, tetracycline, aspirin and NSAIDs)? (Pill esophagitis can cause
dysphagia.)

AIDs: acquired immune deficiency syndrome; NSAIDs: nonsteroidal anti-inflammatory drugs.

Graphic 68343 Version 7.0

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Representative causes of oropharyngeal dysphagia

Iatrogenic Neurological
Medication side effects (chemotherapy, Brainstem tumors
neuroleptics, etc)
Head trauma
Postsurgical muscular or neurogenic
Stroke
Radiation
Cerebral palsy
Corrosive (pill injury, intentional)
Guillain-Barré syndrome
Infectious Huntington disease
Mucositis (herpes, cytomegalovirus, Candida, Multiple sclerosis
etc)
Polio
Diphtheria
Postpolio syndrome
Botulism
Tardive dyskinesia
Lyme disease
Metabolic encephalopathies
Syphilis
Amyotrophic lateral sclerosis
Metabolic
Parkinson disease
Amyloidosis
Dementia
Cushing's syndrome
Structural
Thyrotoxicosis
Cricopharyngeal bar
Wilson disease
Zenker's diverticulum
Myopathic
Cervical webs
Connective tissue disease (overlap
Oropharyngeal tumors
syndrome)
Osteophytes and skeletal abnormalities
Dermatomyositis
Congenital (cleft palate, diverticula, pouches,
Myasthenia gravis
etc)
Myotonic dystrophy

Oculopharyngeal dystrophy

Polymyositis

Sarcoidosis

Paraneoplastic syndromes

Adapted from: Cook IJ, Kahrilas PJ. AGA: Technical review: Management of oropharyngeal dysphagia. Gastroenterology 1999;
116:455.

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Causes of esophageal dysphagia

Mechanical lesions

Intrinsic

Benign tumors

Caustic esophagitis/stricture

Diverticula

Malignancy

Peptic stricture

Eosinophilic esophagitis

Infectious esophagitis

Pill esophagitis

Postsurgery (laryngeal, esophageal, gastric)

Radiation esophagitis/stricture

Rings and webs

Lymphocytic esophagitis

Extrinsic

Aberrant subclavian artery

Cervical osteophytes

Enlarged aorta

Enlarged left atrium

Mediastinal mass (lymphadenopathy, lung cancer, etc)

Postsurgery (laryngeal, spinal)

Motility disorders

Achalasia

Chagas disease

Primary motility disorders

Secondary motility disorders

Functional

Functional dysphagia

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Differential diagnosis of nonacute dysphagia in adults

* Refer to UpToDate content on evaluation and management of oropharyngeal dysphagia.

¶ Patients with esophageal stricture may report chronic heartburn, whereas patients with esophageal cance
tend to be older and often have weight loss.

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Endoscopic image of eosinophilic esophagitis

This upper endoscopy in a 36-year-old man with dysphagia showed

multiple rings in the proximal to mid esophagus, giving it the
appearance of a trachea. Small whitish papules are also visible
representing eosinophilic abscesses on histology. The patient's
symptoms responded to swallowed (ie, topical) fluticasone.

Courtesy of Eric D Libby, MD.

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Endoscopic image of the esophagus showing

multiple ring-like strictures in a patient with
eosinophilic esophagitis

This upper endoscopy in a patient with eosinophilic esophagitis

showed multiple ring-like strictures in the proximal and mid-
esophagus.

Courtesy of Andres Gelrud, MD and Anthony Lembo, MD.

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Barium swallow in a patient with Plummer Vinson

syndrome

This barium swallow study obtained in a 53-year-old female with

dysphagia and anemia demonstrates an upper esophageal web
(black arrow) immediately above a tight stricture of the esophagus
(white arrow).

Courtesy of Jonathan Kruskal, MD, PhD.

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Esophageal web on barium swallow

This modified barium swallow, obtained in a 45-year-old man with

dysphagia, demonstrates an asymmetric esophageal web arising
from the right side of the upper esophagus (arrow).

Courtesy of Jonathan Kruskal, MD, PhD.

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Esophageal (Schatzki) ring

Endoscopic view of an esophageal (Schatzki) ring, which often

cannot be well visualized unless the lower esophagus is widely
distended. The ring appears as a thin membrane with a concentric
smooth contour that projects into the lumen.

Courtesy of James B McGee, MD.

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Esophageal (Schatzki) ring seen on barium swallow

Esophageal (Schatzki) ring at the gastroesophageal junction

visualized on a barium swallow.

Courtesy of Peter J Kahrilas, MD.

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Achalasia

Barium esophagram showing a dilated esophagus and bird's beak

appearance typical of achalasia. Retained food is also visible.

Courtesy of Ram Dickman, MD.

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Dilation of the esophagus in a patient with

achalasia (barium esophagram)

Barium esophagram in a 62-year-old man demonstrates a dilated,

barium-filled esophagus with a region of persistent narrowing
(arrow) at the gastroesophageal junction, producing the so-called
bird's beak appearance. Achalasia was confirmed with manometry
and the patient underwent successful dilation of the esophagus.

Courtesy of Jonathan Kruskal, MD.

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Diffuse esophageal spasm

This barium swallow in an older man with noncardiogenic chest pain

shows multiple areas of spasm (arrows) throughout the length of
the esophagus. This spasm was accentuated by stasis within the
esophageal lumen and esophagitis.

Courtesy of Jonathan Kruskal, MD, PhD.

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Corkscrew esophagus

Esophagram performed in a 72-year-old man with intractable

retrosternal pain and reflux shows marked spasm throughout the
length of the esophagus, which produces a corkscrew-like
appearance.

Courtesy of Jonathan Kruskal, MD, PhD.

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Approach to the patient with esophageal dysphagia

GERD: gastroesophageal reflux disease.

* Performing a barium swallow prior to an upper endoscopy is controversial.

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Contributor Disclosures
Ronnie Fass, MD Equity Ownership/Stock Options: Ginger-Health[GERD]. Grant/Research/Clinical Trial
Support: Salix [Small bowel bacterial overgrowth]. Consultant/Advisory Boards:
Celexio[GERD];Dexcal[GERD];GERDCare[GERD];Medtronics [Esophageal manometry];Phantom
[GERD];Takeda [GERD]. Speaker's Bureau: Adcock-Ingram[GERD];AstraZeneca [GERD];Eisai [GERD];GI
Supply[Esophageal manometry];Johnson & Johnson [GERD];Medicamenta[GERD];Takeda [GERD]. All of the
relevant financial relationships listed have been mitigated. Mark Feldman, MD, MACP, AGAF, FACG No
relevant financial relationship(s) with ineligible companies to disclose. Kristen M Robson, MD, MBA,
FACG No relevant financial relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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