Rosen & Barkin's 5-Minute Emergency Medicine Consult (227 page)

See Also (Topic, Algorithm, Electronic Media Element)

• Amenorrhea
  
• Vaginal Bleeding
  

CODES

• 626.2 Excessive or frequent menstruation
  
• 626.6 Metrorrhagia
  
• 626.8 Other disorders of menstruation and other abnormal bleeding from female genital tract
  

BASICS

• Difficulty swallowing
  
• Can be neuromuscular or mechanical
  

• Oropharyngeal (transfer) dysphagia:
  
  • Difficulty transferring from the mouth to the proximal esophagus (difficulty initiating a swallow)
    
  • Easier to swallow solids vs. liquids
    
  • Immediate, within seconds of swallowing
    
  • Associated with nasal or oral regurgitation, coughing, or choking
    
  • Usually a neuromuscular disorder resulting in bulbar muscle weakness or impaired coordination
    
• Esophageal (transport) dysphagia:
  
  • Failure of normal transit through the esophagus
    
  • Retrosternal sticking sensation seconds after swallowing
    
  • Nocturnal regurgitation/aspiration
    
  • Drooling or regurgitation of undigested food and liquid (characteristic of esophageal obstruction)
    
  • Motility disorder vs. mechanical obstruction
    
• Functional dysphagia:
  
  • Diagnosis of exclusion
    
  • Full workup without evidence of mechanical or neuromuscular pathology
    
  • Symptoms >12 wk
    
• Odynophagia:
  
  • Pain with swallowing
    
  • Separate, but often related, entity
    
• Pain pattern:
  
  • Overall poor ability to localize pain with dysphagia, although oropharyngeal source is better
    
  • Somatic nerve fibers in the upper esophagus; better pain localization
    
  • Visceral pain from the lower esophagus is poorly localized and may be difficult to distinguish from that of acute coronary syndrome.
    

• Pediatric dysphagia:
  
  • Common causes in infants/newborns include prematurity, congenital malformations, neuromuscular disease, infection (e.g., candidiasis), inflammation
    
  • Always consider foreign body aspiration in a child presenting with dysphagia
    
  • Other common causes in children include caustic ingestions, infections, and neurologic disorders including sequelae from head injury
    
  • Acquired tracheoesophageal fistula in children may result from ingestions (disk battery, caustic ingestions) or prior surgery
    
  • Other life-threatening causes of dysphagia include epiglottitis, retropharyngeal abscess, CNS infection, botulism, esophageal perforation, diphtheria
    

DIAGNOSIS

• Difficulty initiating swallowing
  
• Sensation of food stuck after swallowing
  
• Cough/choke after eating
  
• Impairment of gag reflex and ability to clear bolus
  
• Voice change/dysphonia
  
• Drooling
  
• Dysarthria
  
• Chest pain
  

• Is there difficulty swallowing solids, liquids, or both?
  
  • Solids and liquids suggest a neuromuscular disorder.
    
  • Solids only or progression from solids to liquids suggests a mechanical abnormality.
    
• How long after swallowing do symptoms occur?
  
  • Immediate onset of symptoms suggests oropharyngeal cause
    
  • Delay (seconds after swallowing) suggests esophageal cause
    
• Are symptoms intermittent or progressive?
  
  • Intermittent symptoms suggest rings or webs.
    
  • Progressive symptoms suggest peptic or malignant strictures.
    
  • Motility disorders can be intermittent or progressive.
    
• How long have the symptoms been present?
  
  • Acute onset is more concerning for acutely life-threatening etiology
    
  • Food impaction is the most common cause of acute-onset dysphagia
    
  • Malignancy may also progressive relatively quickly
    
• Are there other associated symptoms?
  
  • e.g., nasal regurgitation, choking, heartburn, weight loss
    

• Often unremarkable
  
• Oropharyngeal inspection
  
• Pulmonary and cardiac auscultation
  
• Neurologic exam with emphasis on cranial nerves (esp. V, VII, IX, X, XII)
  

• Adequate airway evaluation
  
• Thorough neurologic exam
  

EKG:

• Consider cardiac etiology for chest discomfort
  

No specific studies are indicated.

• CXR:
  
  • Achalasia food dilating the esophagus may be seen as widened mediastinum, air–fluid level in posterior mediastinum
    
  • Aspiration pneumonitis
    
  • Extrinsic compressing mass
    
• Soft tissue lateral neck radiograph
  
• Modified barium swallow (with solid bolus) or videofluoroscopy:
  
  • Defines esophageal anatomy
    
  • Assesses function
    
  • Do not perform if endoscopy anticipated
    
• CT/MRI of the head:
  
  • Indicated for new-onset neuromuscular dysphagia
    

• Often performed in the outpatient setting
  
• Upper endoscopy:
  
  • Indicated to relieve obstruction and inspect the esophageal anatomy
    
  • Biopsy possible if indicated
    
• Esophageal manometry
  
• Fiberoptic nasopharyngeal laryngoscopy
  

• Oropharyngeal:
  
  • Infectious:
    
    • Botulism
      
    • CNS infections
      
    • Mucositis
      
    • Lyme disease
      
  • Mechanical:
    
    • Congenital
      
    • Malignancy
      
    • Pharyngeal pouch
      
  • Medications:
    
    • Antibiotics (especially doxycycline)
      
    • Aspirin and NSAIDs
      
    • Bisphosphonates
      
    • Ferrous sulfate
      
    • Potassium chloride
      
    • Quinidine
      
  • Neuromuscular:
    
    • Amyotrophic lateral sclerosis
      
    • Cerebrovascular accident
      
    • Guillain–Barré syndrome
      
    • Cranial nerve palsy
      
    • Huntington chorea
      
    • Multiple sclerosis
      
    • Myasthenia gravis
      
    • Parkinson disease
      
    • Traumatic brain injury
      
  • Psychological/behavioral
    
• Esophageal:
  
  • Mechanical:
    
    • Diverticula
      
    • Esophageal webs
      
    • Foreign body
      
    • Neoplasm
      
    • Peptic esophageal stricture
      
    • Postsurgical (laryngeal, spinal)
      
    • Radiation injury
      
    • Schatzki ring
      
  • Motor:
    
    • Achalasia
      
    • Chagas
      
    • Cushing syndrome
      
    • Diffuse esophageal spasm
      
    • Hyperthyroidism/hypothyroidism
      
    • Nutcracker esophagus
      
    • Scleroderma
      
    • Vitamin B
      ₁₂
      deficiency
      
  • Inflammatory:
    
    • Eosinophilic esophagitis
      
    • Pill esophagitis
      
  • Extrinsic:
    
    • Cardiovascular abnormalities (vascular rings, thoracic aneurysm, left atrial enlargement, aberrant subclavian artery)
      
    • Cervical osteophytes
      
    • Mediastinal mass
      

TREATMENT