8/10 Morning Report w/ Alice Zhang: Diagnosing Dysphagia

A middle aged gentleman with no significant past medical history who presents with 2 months of progressive dysphagia.  EGD demonstrated an ulcerating mass with pathology revealing squamous cell cancer.  He subsequently underwent CT scan for staging and PEG tube placement for tube feeding.

Dysphagia Pearls – broken down into oropharyngeal vs. esophageal

Oropharyngeal – dysphagia occurs instantaneously upon swallowing. Order “videofluoroscopy” aka “modified barium swallow” as initial eval.

Neuro – most common cause!:  CVA , Parkinson’s, Myasthenia Gravis

Structural: Thyromegaly, Zenker’s Diverticulum, Neoplasm


Esophageal – split into structural vs. motility disorders. Order EGD as initial eval.

-Intermittent Solid Food Dysphagia:  Think Eosinophilic Esophagitis vs. Schatzki Ring

-Liquid/Solid Dysphagia: Think Motility Disorder

-Progressive Solid Food Dysphagia:  Think Malignancy

Practical Tips for the WARDZ when you are trying to determine if it is safe to write a diet!

***If you have a low suspicion for oropharyngeal dysphagia, you can order a bedside swallow screen to be done by the nurse.  The nurse will simply observe the patient drinking water and pass the patient if he/she does not choke.

***For inpatients with dysphagia to make a formal diagnosis of oropharyngeal dysphagia, you need speech therapy assisted videofluoroscopy [a speech therapist and a radiologist work together to watch the swallowing mechanics under fluoro] to make a formal diagnosis of neuromuscular dysphagia [not just a regular barium swallow!!] – consider this dx in someone with a history of stroke – do not order this without first consulting speech therapy.


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