This week in Morning Report, we discussed a few cases of patients presenting with concerns of ‘food getting stuck’. (These are all de-identified amalgamations of a few patient presentations I’ve encountered over the past few years.)

1. A young man with well-controlled asthma and a recurrent history of food getting stuck going down, now presenting with significant chest pain and ‘stuck’ sensation after eating a meal of spaghetti-and-meatballs. He looks uncomfortable. He is protecting his airway but self-suctioning copious amounts of salivary secretions.
2. An older woman with 3 months of throat pain, pain with swallowing, hoarse voice, and sensation of solids/liquids getting stuck partway through her chest. She has had 20lbs of unintentional weight loss.
3. An older woman with progressive dysphagia to solids and liquids for several months, accompanied by general fatigue, dysarthria, and arm weakness.
4. An elderly gentleman with a history of CAD, CHF, and COPD, admitted for community-acquired pneumonia. You notice while he is in hospital that he is regurgitating a significant amount of his meal tray (solids and liquids), and he tells you this has been going on for ‘some time’.
5. A young woman with subjective intermittent sensation of ‘food getting stuck going down’, with mild bloating. She has no accompanying weight loss or systemic symptoms.

Each of these patients is experiencing dysphagia, or a subjective sensation of difficulty or discomfort with swallowing. Dysphagia is an extremely common presenting concern in primary care and internal medicine – both in the ambulatory setting and in up to 25% of hospitalized patients – and can be a sign of a vast and heterogenous spectrum of diseases.

Let’s recap the approach to dysphagia we discussed!

1. First, a quick anatomy and physiology refresher

A key part of understanding pathology is remembering your anatomic correlates (i.e., why things happen where they happen). Remember that:

• The upper third or so of the esophageal wall is composed of striated muscle, the lower third of smooth muscle, and the middle third is a mix of the two
• Most esophageal adenocarcinomas occur in the lower third of the esophagus (due to proximity to the lower esophageal sphincter and exposure to gastric acid), while squamous cell carcinomas occur in the mid esophagus or higher up in the head-and-neck region
• The myenteric plexus (Auerbach’s plexus) provides parasympathetic and sympathetic innervation to the gut and is responsible for peristalsis. Diseases involving this plexus are often implicated in motility disorders (e.g., achalasia, pseudoachalasia).

• Swallowing is a complex series of actions including a preparatory phase (chewing/mixing of the food bolus), a transit phase where the bolus is propelled backwards towards the pharynx, a complex pharyngeal phase involving closure of the nasopharynx and airway, with movement of the bolus into the proximal esophagus, and finally, involuntary contractions of the esophagus to propel the food bolus into the stomach. This is shown nicely in the video below.

2. Recall your basic approach to dysphagia, with a few additional history-taking pearls

As we all learned in medical school, a good first branching point in your approach to dysphagia is to determine whether the patient is experiencing oropharyngeal dysphagia (difficulty initiating the swallow) or esophageal dysphagia (no difficulty initiating the swallow, but a sensation of things getting stuck after the swallow). A few pearls here:

• Oropharyngeal dysphagia may often be associated with nasal regurgitation, coughing/choking sensation, and ‘wet’ or hoarse voice
• A few high-risk groups in whom oropharyngeal dysphagia is particularly prevalent: elderly individuals, patients with H&N cancers, patients with neurodegenerative illnesses
• Patients will often point to where they feel the food is getting stuck (e.g., mid-chest, or at the sternoclavicular notch). This does not reliably correlate to the actual location of obstruction!
• Remember that Diagnosis = Localization x Timecourse. It’s really important to nail down how long the patient has been experiencing symptoms, whether they are intermittent or constant, unchanged or progressively worsening
• Dysphagia in itself is an alarm symptom, but don’t forget to ask about others: unintentional weight loss, anemia, GI Bleeding, vomiting

3. Structure your differential diagnosis based on localization and timecourse

A good way of remember differential diagnoses for causes of dysphagia is to think about the two main ways in which things can go wrong: structural/anatomic problems (masses, strictures, lumps) or neurological problems (stroke effects, motility disorders, neuromuscular disorders, etc.).

We went through a long differential together – this is nicely summarized in the Harrison’s flow chart below:

4. Remember the following associations – high yield for exams!

A few key ‘clang associations’ are high yield and worth knowing for various exam scenarios (and real life!). I’ve summarized them below:

BONUS: Don’t forget dysphagia lusoria – where aberrant vasculature (most commonly an aberrant subclavian artery, but occasionally large/tortuous aortic aneurysms) cause mechanical compression of the esophagus.

5. Know which tests to order based on your clinical suspicion

• Oropharyngeal dysphagia: This is generally in the domain of our colleagues in Otolaryngology, who will often perform flexible nasopharyngoscopy to identify structural lesions. If a motility, neurological, or neuromuscular disorder is suspected, a barium-based swallowing study provides an excellent dynamic assessment (but is more limited at identifying structural lesions).
• Esophageal dysphagia: Any concerning alarm symptoms or suspicion of structural lesions should be investigated with an upper endoscopy, which can be diagnostic and therapeutic depending on the diagnosis. If no structural abnormalities are identified and a motility disorder is suspected, esophageal manometry is the next test of choice.

6. Case Wrap-Up

We briefly discussed the workup and diagnosis for each of the cases I introduced:

1. A young man with well-controlled asthma and a recurrent history of food getting stuck going down, now presenting with significant chest pain and ‘stuck’ sensation after eating a meal of spaghetti-and-meatballs. Eosinophilic Esophagitis – confirmed with OGD showing trachealization of the esophagus, linear furrows, and +++Eos per high powered field!
2. An older woman with 3 months of throat pain, pain with swallowing, hoarse voice, and sensation of solids/liquids getting stuck partway through her chest. She has had 20lbs of unintentional weight loss. Squamous Cell Carcinoma of the Upper Esophagus, diagnosed by OGD.
3. An older woman with progressive dysphagia to solids and liquids for several months, accompanied by general fatigue, dysarthria, and arm weakness. Significant neuromuscular dysfunction, normal OGD. Ultimately underwent comprehensive neurological evaluation and was diagnosed with motor neuron disease.
4. An elderly gentleman with a history of CAD, CHF, and COPD, admitted for community-acquired pneumonia. You notice while he is in hospital that he is regurgitating a significant amount of his meal tray (solids and liquids), and he tells you this has been going on for ‘some time’. Ultimately diagnosed with pseudoachalasia due to lung cancer.
5. A young woman with subjective intermittent sensation of ‘food getting stuck going down’, with mild bloating. She has no accompanying weight loss or systemic symptoms. All investigations were thankfully reassuring – esophageal hypervigilance and functional dyspepsia.

I hope you found this Morning Report useful – thanks for participating!