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How I Approach Dysphagia

  • Jooho P. Kim
  • Peter J. KahrilasEmail author
Esophagus (J Clarke and N Ahuja, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Esophagus

Abstract

Purpose of Review

This review presents an overview of the diagnostic approach to esophageal dysphagia and summarizes recent epidemiological trends and technical advancements.

Recent Findings

The evaluation of dysphagia begins with a detailed history followed by endoscopy to evaluate for any structural abnormalities including malignancy. This is especially true given the emergence of eosinophilic esophagitis (EoE) as a dominant cause of esophageal dysphagia. In fact, it is now standard practice to obtain esophageal biopsies during endoscopy performed to evaluate dysphagia, since EoE can present without the characteristic mucosal features of rings, furrows, and exudate. Achalasia is also more frequently encountered since the introduction of high-resolution manometry (HRM) and the Chicago Classification into clinical practice. The Chicago Classification provides a stepwise diagnostic algorithm for evaluating HRM studies and systematically diagnosing esophageal motility disorders. Lastly, the functional lumen imaging probe (FLIP) is a novel technology that has added insight into both achalasia and EoE. Measuring esophageal distensibility with FLIP has useful prognostic implications for both diseases, and FLIP can identify motility abnormalities in achalasics not detected with HRM.

Summary

A careful history is key to the efficient evaluation of dysphagia, and endoscopy is usually the first diagnostic study to obtain. For patients with prominent reflux symptoms, an empiric trial with proton pump inhibitors is reasonable then because reflux disease is such a common cause of dysphagia. Thereafter, patients should undergo HRM to evaluate for a motility disorder, and FLIP can provide complementary data to guide management.

Keywords

Esophagus Dysphagia High-resolution manometer Functional luminal imaging probe 

Abbreviations

DCI

distal contractile integral

DL

distal latency

EGD

esophagogastroduodenoscopy

EGJ

esophagogastric junction

EGJOO

esophagogastric junction outflow obstruction

EoE

eosinophilic esophagitis

FLIP

functional lumen imaging probe

GERD

gastroesophageal reflux disease

HRM

high-resolution manometry

IEM

ineffective esophageal motility

IRP

integrated relaxation pressure

PPI

proton pump inhibitor

Notes

Funding Information

Peter J Kahrilas was supported by P01 DK117824 (PI John E. Pandolfino) from the US Public Health Service.

Compliance with Ethical Standards

Conflict of Interest

Peter Kahrilas shares a patent with Drs John Pandolfino and Zhiyue Lin for the intellectual property behind FLIP panometry.

Jooho Kim declares no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Feinberg School of Medicine, Department of MedicineNorthwestern UniversityChicagoUSA

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