Complaints of dysphagia, odynophagia, or ingested foreign body usually imply esophageal disease. Chest pain, upper gastrointestinal (GI) bleeding, malignancy, and mediastinitis may also be esophageal in nature. Many diseases of the esophagus can be evaluated over time in an outpatient setting, but several, such as esophageal foreign body and esophageal perforation, require emergent evaluation.
Dysphagia is difficulty with swallowing. Most patients with dysphagia have an identifiable organic cause. The two broad pathophysiologic groups of dysphagia are transfer dysphagia (oropharyngeal) and transport dysphagia (esophageal).
A careful history is the key to the diagnosis of dysphagia. Determine whether solids, liquids, or both cause the symptoms and the time course and progression of symptoms. Dysphagia for solids that progresses to liquids suggests a mechanical or obstructive process. Dysphagia for both solids and liquids points to a motility disorder. A poorly chewed meat bolus may obstruct the esophagus and be the presenting sign for a variety of underlying esophageal pathologies. Esophageal filling proximal to the impacted bolus can cause inability to swallow secretions and can present an airway or aspiration risk. Physical examination of patients with dysphagia should focus on the head and neck and the neurologic examination, although the examination is often normal.
Diagnosis and Differential
The diagnosis of the underlying pathology of dysphagia is most often made outside the emergency department (ED). ED evaluation may include anteroposterior and lateral neck and chest x-rays. Direct laryngoscopy may identify lesions. Structural or obstructive causes of dysphagia include neoplasms (squamous cell is most common), esophageal strictures and webs, Schatzki ring, and diverticula. Motor lesions causing dysphagia include neuromuscular disorders (cerebrovascular accident is most common), achalasia, diffuse esophageal spasm, and esophageal dysmotility.
Emergency Department Care and Disposition
Aspiration is a major concern with most causes of dysphagia.
Most causes of dysphagia can be further evaluated and managed in the outpatient setting using a variety of tools including barium swallow (often first test), video esophagograpy, manometry, and esophagoscopy.
Many of the structural lesions ultimately will require dilatation as definitive therapy.
CHEST PAIN OF ESOPHAGEAL ORIGIN
Differentiating esophageal pain from ischemic chest pain is difficult at best and may be impossible in the ED. Patients with esophageal pain report symptoms that are also found in patients with coronary artery disease, and there is no historical feature that is sensitive or specific enough to differentiate the two. The best ED default assumption is that pain is cardiac in nature and not esophageal until proven otherwise.
Gastroesophageal Reflux Disease
Reflux of gastric contents into the esophagus causes a wide array of symptoms and long-term effects.
Heartburn is the classic symptom of gastroesophageal reflux disease (GERD), although chest discomfort may be the ...