Review
Oesophageal dysphagia: a stepwise approach to diagnosis and management

https://doi.org/10.1016/S2468-1253(17)30001-8Get rights and content

Summary

Dysphagia is a common symptom in the general population. Incidence varies depending on the specific definition used. A good medical history is vital for distinguishing true oesophageal dysphagia from oropharyngeal dysphagia or other causes. Oesophageal dysphagia is a so-called red flag alarm symptom requiring oesophagogastroduodenoscopy. However, even after investigations including oesophagogastroduodenoscopy (with biopsy), barium swallow, and oesophageal manometry, no obstructive cause may be found. This Review suggests an algorithm of history-taking and investigation to allow the causes of non-obstructive dysphagia to be identified, including functional dysphagia. The Review then discusses management strategies and outcomes for functional dysphagia.

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

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.

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