Determining the Cause

Chief Complaint: Dysphagia

a. History: Difficulty initiating swallowing

Differential Diagnosis

Suggests oropharyngeal dysphagia

 

 

 

Pivotal Assessment	Findings

 

1. Clinical History

• Nature of Dysphagia:
  • Difficulty initiating swallowing suggests oropharyngeal dysphagia.
  • Sensation of food sticking in the chest suggests esophageal dysphagia.
• Type of Food:
  • Difficulty swallowing solids suggests a structural cause (e.g., strictures, tumors).
  • Difficulty with solids and liquids from the onset suggests a motility disorder (e.g., achalasia).
• Progression: Gradual onset indicates a progressive condition; sudden onset suggests acute issues like a stroke.
• Associated Symptoms: Regurgitation, weight loss, chest pain, or neurological symptoms (e.g., weakness, difficulty speaking) provide clues.

2. Physical Examination

• Check for signs of neurological deficits, such as cranial nerve abnormalities.
• Assess oral cavity and throat for structural abnormalities or inflammation.
• Examine for systemic conditions like scleroderma or myopathy.

3. Diagnostic Tests

• Barium Swallow (Esophagram): Evaluates the structure and motility of the esophagus and oropharynx.
• Endoscopy (EGD): Allows direct visualization of the esophagus, stomach, and duodenum to identify structural abnormalities, inflammation, or tumors.
• Esophageal Manometry: Measures esophageal pressure and motility, useful for diagnosing motility disorders like achalasia or diffuse esophageal spasm.
• Videofluoroscopic Swallow Study: Assesses the swallowing process, particularly in oropharyngeal dysphagia.
• pH Monitoring: Helps detect gastroesophageal reflux as a potential cause.

4. Specialized Testing

• Neurological Evaluation: If a central or peripheral nervous system disorder is suspected, imaging (MRI/CT) and neurological consultation may be necessary.
• Imaging Studies: CT or MRI may identify structural causes like tumors or extrinsic compression.
• Biopsy: Taken during endoscopy if malignancy or specific conditions like eosinophilic esophagitis are suspected.

5. Multidisciplinary Approach

• In complex cases, collaboration among gastroenterologists, neurologists, ENT specialists, radiologists, and speech-language pathologists is essential.

Understanding the underlying cause guides targeted treatment, which could range from dietary modifications to medical, surgical, or rehabilitative therapies.

 

 

Pivotal Assessment	Finding

 

 

Dysphagia

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