dysphagia/Heartburn

dysphagia/Heartburn: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

Dysphagia

❑ Infectious esophagitis

❑ Reflux stricture

❑ Zenker diverticulum

❑ Transfer dysphagia

❑ Diffuse esophageal spasm

❑ Foreign body

❑ Esophageal cancer

❑ Achalasia

❑ External compression

❑ Scleroderma

❑ Myasthenia gravis

❑ Radiation injury

❑ Globus hystericus

❑ Esophageal web

❑ Botulism

Heartburn

❑ Reflux esophagitis

❑ Drugs

❑ Gastritis

❑ Pregnancy

❑ Aerophagia

❑ Infectious esophagitis

❑ Scleroderma

Diagnostic Approach

Dysphagia, a sensation of sticking usually occurs at the level of the obstruction, although distal esophageal obstruction may be referred to the suprasternal notch. Odynophagia (painful swallowing) is usually caused by infectious esophagitis (Candida, HSV, CMV), severe reflux, or pill-induced esophagitis. Phagophobia (fear of swallowing) can occur in patients with hysteria, rabies, tetanus, or pharyngeal paralysis.

Weight loss may occur with dysphagia of any cause, but a major loss disproportionate to the dysphagia suggests cancer. Hoarseness occurring before dysphagia is consistent with a laryngeal lesion. Hoarseness occurring after the onset of dysphagia suggests recurrent laryngeal involvement with esophageal or bronchogenic cancer or laryngitis due to reflux or neuromuscular disease. Hiccups signal a problem in the terminal esophagus (cancer, achalasia, hiatal hernia). Progressive dysphagia is usually caused by cancer or a peptic stricture, while intermittent dysphagia is most often due to a lower esophageal ring. Unilateral wheezing with dysphagia indicates a mediastinal mass involving both the esophagus and bronchus.

History differentiates mechanical obstruction from motor disorders with 80% accuracy.

Heartburn is typically a retrosternal burning, occurring after meals or awakening the patient from sleep. Patients may regurgitate acid and small amounts of undigested food without nausea or retching. Less common symptoms include water brash, a foamy reflex hypersalivation, and globus, the constant sensation of a lump in the throat. The correlation between severity of heartburn and endoscopic grade of esophagitis is poor.

Early evaluation is indicated by coincident symptoms such as dysphagia, severe nausea, vomiting, weight loss or bleeding, lack of response to empiric therapy, or increase in symptoms with exertion (suggesting angina). Heartburn can mimic angina, with chest pressure radiating to the jaw or shoulder. Pain
or difficulty swallowing suggests active inflammation, malignancy, achalasia, or stricture. Nocturnal pain relieved by intake of food, milk, or antacids favors
peptic ulcer disease. Pain increased by meals and not interfering with daily
activities favors nonulcer dyspepsia.

Clinical Findings

Infectious esophagitis  The main symptoms are heartburn and odynophagia with swallowing saliva alone. Oral thrush is a clue to Candida esophagitis; vesicles, to herpes simplex. Mucositis may occur with radiation or chemotherapy. Cytomegalovirus esophagitis is frequently seen in those with HIV infection as part of a systemic infection along with hepatitis and retinitis.

Reflux stricture  A Schatzki ring, occurring with longstanding reflux/heartburn, causes a sensation of distal obstruction. Dysphagia is intermittent and for solid food only (the classic onset occurs with swallowing meat). There is chest
discomfort relieved by regurgitation of the bolus or drinking liquids.

Zenker diverticulum  Halitosis and regurgitation are clues.

Transfer dysphagia  The patient complains of food getting stuck in the neck immediately upon swallowing. There is difficulty initiating swallowing of solids or liquids. Aspiration with cough after swallowing, fluid expectoration through the nose, nasal speech, dysphonia, and dysarthria may also be present. Causes include pseudobulbar palsy, myasthenia gravis, dermatomyositis, and muscular dystrophy.

Diffuse esophageal spasm  Symptoms include intermittent dysphagia associated with chest pain and triggered by cold or heat.

Foreign body  Occurring suddenly while eating, it is usually caused by fish or chicken bones. There is a distinct, well-localized sensation of the foreign body.

Esophageal cancer  Marked weight loss and progressively increasing dysphagia over weeks are characteristic. There is often chest pain and odynophagia. Occasionally, hyperkeratotic palms and soles appear.

Achalasia  Pain with eating or drinking rapidly is caused by vigorous tertiary contractures. Food can be consumed if eaten slowly. Regurgitation occurs with changes in position (e.g., nocturnal) or exercise. Foul breath is noted from food in the esophagus.

External compression  Compression is suggested by the symptom complex of dysphagia and unilateral wheezing, with concurrent hoarseness if the recurrent laryngeal is involved. Causes include thyromegaly, mediastinal mass, descending thoracic aortic aneurysm, paraesophageal diaphragmatic hernia, left atrial enlargement, prior radiation, and surgery. Atrial enlargement occurs with mitral valvular disease, and compresses the esophagus in the lower third.

Scleroderma  Consider scleroderma in a patient with heartburn and dysphagia to solids, especially with concomitant Raynaud syndrome and subtle tightening/binding of the skin and telangiectasias on the hands and face.

Myasthenia gravis  Progressive fatigue occurs with repeated swallowing. Bilateral ptosis is common.

Radiation injury  Acutely, patients develop esophagitis with odynophagia. Later a strucure may develop at the site of maximal dose.

Globus hystericus  There is a constant lump in the throat with a sensation of food sticking at the cricoid. Symptoms can be unrelated to or relieved by swallowing. There may be a history of hysterical aphonia.

Esophageal web  Dysphagia is usually intermittent. Iron deficiency anemia, with pica (clay or ice craving), and pallor, is present.

Botulism  Nausea, vomiting, and stiff tongue rapidly progress to aphonia and aphagia. Symmetrical ptosis and strabismus are present.

Reflux esophagitis  Reflux is experienced as a retrosternal burning sensation, radiating upward. It is often accompanied by spontaneous appearance of fluid in the mouth, tasting acidic (gastric), salty (reflex salivary hypersecretion, “water brash”), or bitter (bile). Symptoms may be exacerbated by lying in the supine position, bending forward, or consuming large meals. Accompanying symptoms may include chest pain, nocturnal cough, hoarseness, repetitive throat clearing, and appearance of frothy mucus in the throat.

Drugs  Lower esophageal sphincter tone may be decreased and symptoms exacerbated, by anticholinergics, theophylline, meperidine, calcium-channel blockers, tobacco, alcohol, chocolate, and peppermint. Tetracycline, aspirin, iron, and quinidine may cause direct esophageal injury (“pill esophagitis”).

Gastritis  There is constant epigastric burning, which is relieved by consuming food or antacids.

Pregnancy  Heartburn may occur because of increased intra-abdominal pressure and decreased lower esophageal sphincter tone may be due to estrogens and progesterone.

Aerophagia  Recurrent eructation (burping) is due to swallowed air. Common precipitants include anxiety, carbonated beverages, gum chewing, postnasal drainage, and esophageal speech.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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