The search terms “functional dysphagia” and “non-obstructive dysphagia” were entered into PubMed for full-text articles and abstracts in the English language published in the past 10 years. This was initially done on May 4, 2016, and updated on Oct 4, 2016.
ReviewOesophageal dysphagia: a stepwise approach to diagnosis and management
Introduction
The prevalence of dysphagia in the general population is around 20%, and it is estimated to affect up to 50% of people over the age of 60 years.1 Wilkins and colleagues2 reported that 22·6% of the general population experienced dysphagia at least several times per month and that it occurred more frequently in women and in older people than in men and in younger people. Dysphagia prevalence was based on the question: “Approximately, how often do you have a problem swallowing, that is, having the feeling that food gets stuck in your throat or chest, or coughing or choking with swallowing?” Cho and colleagues3 have defined dysphagia as difficulty swallowing (a feeling that food sticks in your throat or chest). In their study, 19·5% of questionnaire responders had dysphagia under this definition, with 3% of participants reporting dysphagia at least once a week. However, the questions used in these two studies did not discriminate between an oropharyngeal and an oesophageal origin of the dysphagia.
One study of more than 5000 US households investigated the community prevalence of functional dysphagia (defined as dysphagia with all self-reported obstructive causes excluded).4 The investigators estimated a national prevalence of functional dysphagia of 6·0–7·7%. This represents a substantial burden of disease, with more than 50% of cases going unreported.4, 5
Section snippets
History
A focused history and an awareness of potential diagnoses will help to identify true oesophageal dysphagia. First, it is important to consider alternate diagnoses that are not true dysphagia. Globus is a sensation of something present in the throat at rest, which improves or disappears with swallowing food. Xerostomia (insufficient saliva) is present in 16% of elderly men and 25% of elderly women aged 70 years or older,6 and can give rise to the sensation of difficulty swallowing food.
Second,
Investigation
Panel 2 lists the investigations that need to be completed before labelling dysphagia as functional. The three core tests are oesophagogastroduodenoscopy with upper oesophageal biopsy, barium swallow with a 13 mm tablet or barium-impregnated marshmallow, and oesophageal manometry. The major motor disorders are achalasia and oesophagogastric junction outflow obstruction, distal oesophageal spasm, hypercontractile oesophagus, and absent peristalsis. These disorders, which are diagnosed on
Reduce current motility-altering medication
The first step in management of functional dysphagia is to ask about (and, if possible, reduce) use of opioid and other motility-altering drugs. Chronic opioid users who have been studied while on medication were significantly more likely to have major motor disorders including oesophagogastric junction outflow obstruction (18 [27%] of 66) compared with those studied after at least 24 h off their medication (four [7%] of 55, p=0·004).20
Other drugs associated with dysphagia include those that
Prognosis
The prognosis of functional dysphagia is good, particularly if a minor motility disorder is diagnosed. A follow-up study50 of patients diagnosed with ineffective oesophageal motility noted that, in 70% of patients, the symptoms improved or disappeared over a 3-year period. In another follow-up study51 of patients who had high-resolution manometry, only 16% continued to have significant dysphagia after a mean follow-up of 6 years. The study found that patients with minor motor abnormalities had
Conclusions
Dysphagia is a common symptom in the general population and is often unreported. True oesophageal dysphagia is an alarm symptom requiring urgent investigation, but when the core investigations of oesophagogastroduodenoscopy, barium swallow, and oesophageal manometry are negative, a diagnosis of functional dysphagia can be made. Appropriate management of functional dysphagia requires consideration of the possible causes; however, with appropriate treatment, functional dysphagia has a good
Search strategy and selection criteria
References (52)
- et al.
Esophageal dilation
Gastrointest Endosc
(2006) - et al.
The short- and long-term efficacy of empirical esophageal dilation in patients with nonobstructive dysphagia: a prospective, randomized study
Am J Gastroenterol
(2000) - et al.
Dysphagia without endoscopically evident disease: to dilate or not?
Am J Gastroenterol
(2001) - et al.
Short-term cognitive behavioral therapy for non-cardiac chest pain and benign palpitations: a randomized controlled trial
J Psychosom Res
(2011) - et al.
Long-term outcomes of patients with normal or minor motor function abnormalities detected by high-resolution esophageal manometry
Clin Gastroenterol Hepatol
(2015) Resolution expressing the sense of the Congress that a National Dysphagia Awareness Month should be established. 110th Congress. 2nd session. H Con Res 195 (2008)
(2008)- et al.
The prevalence of dysphagia in primary care patients: a HamesNet Research Network study
J Am Board Fam Med
(2007) - et al.
Prevalence and risk factors for dysphagia: a USA community study
Neurogastroenterol Motil
(2015) - et al.
US householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact
Dig Dis Sci
(1993) Dysphagia World Gastroenterology Organisation global guideline
Salivary flow, saliva, pH and buffering capacity in 70-year-old men and women. Correlation to dental health, dryness in the mouth, disease and drug treatment
J Oral Rehabil
Experimental referred pain from the gastrointestinal tract. Part I. The esophagus
J Clin Invest
Discriminative information in the diagnosis of dysphagia
J R Coll Physicians Lond
Diagnostic evaluation of dysphagia
Nat Clin Pract Gastroenterol Hepatol
Symptom overview and quality of life
The Chicago classification of esophageal motility disorders, v3.0
Neurogastroenterol Motil
Current therapeutic options for esophageal motor disorders as defined by the Chicago classification
J Clin Gastroenterol
Revised criterion for diagnosis of ineffective esophageal motility is associated with more frequent dysphagia and greater bolus transit abnormalities
Am J Gastroenterol
Weak peristalsis in esophageal pressure topography: classification and association with dysphagia
Am J Gastroenterol
Manometric oesophageal function, acid perfusion test and symptomatology in a 55-year-old general population
Clin Physiol
Perception of dysphagia: lack of correlation with objective measurements of esophageal function
Neurogastroenterol Motil
Sensation of stasis is poorly correlated with impaired esophageal bolus transport
Neurogastroenterol Motil
Lack of correlation between HRM metrics and symptoms during the manometric protocol
Am J Gastroenterol
Functional esophageal disorders
Gastroenterology
Opioid-induced esophageal dysfunction (OIED) in patients on chronic opioids
Am J Gastroenterol
Drug-induced dysphagia
Dysphagia
Cited by (24)
Apparent Increase in Eosinophilic Esophagitis Prevalence May Reflect Delayed Guideline Adoption
2024, Clinical Gastroenterology and HepatologyDysphagia
2023, Primary Care - Clinics in Office PracticeUnderstanding esophageal symptoms: Dysphagia, heartburn, and chest pain
2023, Handbook of Gastrointestinal Motility and Disorders of Gut-Brain Interactions, Second EditionReduced masticatory function predicts gastroesophageal reflux disease and esophageal dysphagia in patients referred for upper endoscopy: A cross-sectional study
2022, Digestive and Liver DiseaseCitation Excerpt :Our findings support further studies to assess the relationship between chewing dysfunction and dysphagia in eosinophilic esophagitis. We had the caution to control for xerostomia, a potential confounder in the relationship between poor mastication and dysphagia [34]. Xerostomia and GERD have bidirectional relationships, with xerostomia acting as a risk factor for GERD due to decreased esophageal clearance, and GERD acting by decreasing salivary secretion [35].
Dysphagia and Swallowing Disorders
2021, Medical Clinics of North AmericaCitation Excerpt :Esophageal dysphagia symptoms are localized to the neck or chest and can include reflux, food impaction, and chest pain. It is important to note, however, that localization in dysphagia is often nonspecific and mixed.6,13 Management of dysphagia is often dependent on its cause, so accurate diagnosis and understanding of the swallowing mechanism are essential.
The Stanford Multidisciplinary Swallowing Disorders Center
2021, Clinical Gastroenterology and Hepatology