How I Approach Dysphagia
Purpose of Review
This review presents an overview of the diagnostic approach to esophageal dysphagia and summarizes recent epidemiological trends and technical advancements.
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.
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.
KeywordsEsophagus Dysphagia High-resolution manometer Functional luminal imaging probe
distal contractile integral
esophagogastric junction outflow obstruction
functional lumen imaging probe
gastroesophageal reflux disease
ineffective esophageal motility
integrated relaxation pressure
proton pump inhibitor
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.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 8.ASGE Standards of Practice Committee, Pasha SF, Acosta RD, Chandrasekhara V, Chathadi KV, et al. Role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc. 2014;79:191–201.Google Scholar
- 11.Dellon ES, Erichsen R, Baron JA, Shaheen NJ, Vyberg M, Sorensen HT, et al. The increasing incidence and prevalence of eosinophilic oesophagitis outpaces changes in endoscopic and biopsy practice: national population-based estimates from Denmark. Aliment Pharmacol Ther. 2015;41:662–70.PubMedPubMedCentralGoogle Scholar
- 15.Carlson DA, Pandolfino JE. High-resolution manometry in clinical practice. Gastroenterol Hepatol. 2015;11:374–84.Google Scholar
- 16.• Roman S, Huot L, Zerbib F, Bruley des Varannes S, Gourcerol G, et al. High-resolution manometry improves the diagnosis of esophageal motility disorders in patients with dysphagia: a randomized multicenter study. Am J Gastroenterol. 2016;111:372–80 This paper demonstrates the superiority of HRM to conventional manometry in the diagnosis of motility disorders.PubMedGoogle Scholar
- 25.•• Kahrilas PJ, Bredenoord AJ, Carlson DA, Pandolfino JE. Advances in management of esophageal motility disorders. Clin Gastroenterol Hepatol. 2018;16:1692–700 State of the art discussion of the interrelationship between diagnostic modalities in the diagnosis and management of esophageal motility disorders.PubMedPubMedCentralGoogle Scholar
- 28.• Samo S, Carlson DA, Gregory DL, Gawel SH, Pandolfino JE, et al. Incidence and prevalence of achalasia in central Chicago, 2004-2014, since the widespread use of high-resolution manometry. Clin Gastroenterol Hepatol. 2016;15:366–73 This paper explores the rise in prevalence of achalasia over a decade likely due to increased detection of the disease and more accurate diagnoses with HRM.PubMedPubMedCentralGoogle Scholar
- 37.Gyawali CP, Roman S, Bredenoord AJ, Fox M, Keller J, et al. Classification of esophageal motor findings in gastro-esophageal reflux disease: conclusions from an international consensus group. Neurogastroenterol Motil. 2017;29:e13104.Google Scholar
- 38.Xiao Y, Read A, Nicodème F, Roman S, Kahrilas PJ, Pandolfino JE. The effect of a sitting vs supine posture on normative esophageal pressure topography metrics and Chicago Classification diagnosis of esophageal motility disorders. Neurogastroenterol Motil. 2012;24:e509–16.PubMedPubMedCentralGoogle Scholar
- 47.• Nicodème F, Hirano I, Chen J, Robinson K, Lin Z, et al. Esophageal distensibility as a measure of disease severity in patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2013;11:1101–7.e1 This paper demonstrates the prognostic value of FLIP measurements in predicting the risk of food impaction in patients with EoE.PubMedPubMedCentralGoogle Scholar
- 50.• Yoo IK, Choi SA, Kim WH, Hong SP, Cakir OO, et al. Assessment of clinical outcomes after peroral endoscopic myotomy via esophageal distensibility measurements with the endoluminal functional lumen imaging probe. Gut Liver. 2019;13:32–9 This paper reports how FLIP measurements are predictive of treatment response in the setting of achalasia.PubMedGoogle Scholar
- 51.• Ngamruengphong S, von Rahden BH, Filser J, Tyberg A, Desai A, et al. Intraoperative measurement of esophagogastric junction cross-sectional area by impedance planimetry correlates with clinical outcomes of peroral endoscopic myotomy for achalasia: a multicenter study. Surg Endosc. 2016;30:2886–94 This paper illustrates the potential intra-operative role of FLIP to tailor therapy in order to optimize treatment response for patients with achalasia.PubMedGoogle Scholar
- 54.• Carlson DA, Kahrilas PJ, Lin Z, Hirano I, Gonsalves N, et al. Evaluation of esophageal motility utilizing the functional lumen imaging probe. Am J Gastroenterol. 2016;111:1726–35 This paper demonstrates that FLIP may have a greater sensitivity for the detection of achalasia when compared to HRM.PubMedPubMedCentralGoogle Scholar