Dysphagia

Population Covered By The Guidance

This pathway provides guidance on the imaging investigation of adult patients with dysphagia

Lead Researcher: Sian Chin

Experts & Contributors: Ravinder Dhillon, Natasha Dodd

Editorial Panel: Core Membership

Date reviewed: January 2019

Date Published: July 2019

Image 1 (Barium Swallow): Hiatus hernia with a benign oesophageal stricture (arrow).

Benign Oesophageal Stricture

Image 2 (Barium Swallow): Rounded lesion in the mid oesophagus, characteristic of a leiomyoma.

Leiomyoma

Image 3 (Barium Swallow): Demonstrates a cricopharyngeal diverticulum (Zenker's).

Cricopharyngeal Diverticulum

Image 4a : Malignant stricture located at the junction of the middle and distal thirds of the oesophagus, over a length of 2-3cm (arrow). Immediately distal to this is a segment of normal calibre oesophagus, followed by a further segment of narrowing immediately proximal to the gastro-oesophageal junction which has herniated above the diaphragm.

Oesophageal Carcinoma

Image 4b (Barium Swallow): Malignant stricture located at the junction of the middle and distal thirds of the oesophagus, over a length of 2-3cm (arrow). Immediately distal to this is a segment of normal calibre oesophagus, followed by a further segment of narrowing immediately proximal to the gastro-oesophageal junction which has herniated above the diaphragm.

Oesophageal Carcinoma

Image 5a: Arising at the junction from the oesophagus and stomach is a large ulcerating tumour with heaped-up edges and central necrosis.

Oesophageal Carcinoma

Image 5b (H&E, x2.5) : Histological sections of a poorly differentiated squamous cell carcinoma of the oesophagus. There are sheets and nests of malignant squamous cells infiltrating through the oesophageal wall. Note the extensive lymphovascular space invasion (arrows). The cells demonstrate marked nuclear atypia with frequent mitotic figures at high power.

Oesophageal Carcinoma

Image 5c (H&E, x10): Histological sections of a poorly differentiated squamous cell carcinoma of the oesophagus. There are sheets and nests of malignant squamous cells infiltrating through the oesophageal wall. Note the extensive lymphovascular space invasion (arrows). The cells demonstrate marked nuclear atypia with frequent mitotic figures at high power.

Oesophageal Carcinoma

Image 6a : Demonstrates a dilated oesophagus with an air fluid level. There is intermittent opening of the gastro-oesophageal junction due to cardiospasms. The delayed film (Image 6b) shows persisting residue in the oesophagus.

Achalasia

Image 6b (Barium Swallow): Demonstrates a dilated oesophagus with an air fluid level. There is intermittent opening of the gastro-oesophageal junction due to cardiospasms. The delayed film (Image 6b) shows persisting residue in the oesophagus.

Achalasia

  • Clinical history is important for differentiating between oropharyngeal and oesophageal dysphagia
  • Contrast swallow and endoscopy are complementary in the assessment of oesophageal dysphagia
  • There is no hard evidence which of these tests should be performed first
  • If there is a high pre-test probability of malignancy, it is reasonable to perform endoscopy first
  • If there is a lower pre-test probability of malignancy, a contrast swallow may be performed first including assessment of the oropharyngeal phase of swallowing dependant on the history
  • VFSS and FEES are both appropriate initial investigations for oropharyngeal dysphagia; they are complementary investigations
  • Consider Functional Gastrointestinal Disorder (FGID) globus if the criteria are met (according to ROME 3), if met then no routine imaging is usually required
  • If in the clinical assessment of suspected globus other symptoms are apparent then further investigation is required

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

      1. Pasha SF, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, et al. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc. 2014;79(2):191-201. (Guidelines document). View the reference
      2. Lew RJ, Kochman ML. A review of endoscopic methods of esophageal dilation. J Clin Gastroenterol. 2002;35(2):117-26. (Review article). View the reference
      3. Baker ME, Rice TW. Radiologic evaluation of the esophagus: methods and value in motility disorders and GERD. Semin Thorac Cardiovasc Surg. 2001;13(3):201-25. (Review article). View the reference
      4. Levine MS, Rubesin SE. Radiologic investigation of dysphagia. AJR Am J Roentgenol. 1990;154(6):1157-63. (Review article). View the reference
      5. Malagelada JR, Bazzoli F, Boeckxstaens G, De Looze D, Fried M, Kahrilas P, et al. World gastroenterology organisation global guidelines: dysphagia--global guidelines and cascades update September 2014. J Clin Gastroenterol. 2015;49(5):370-8. (Guideline). View the reference
      6. Kruger D. Assessing esophageal dysphagia. JAAPA : official journal of the American Academy of Physician Assistants. 2014;27(5):23-30. (Review). View the reference
      7. Astin MP, Martins T, Welton N, Neal RD, Rose PW, Hamilton W. Diagnostic value of symptoms of oesophagogastric cancers in primary care: a systematic review and meta-analysis. Br J Gen Pract. 2015;65(639):e677-91. (Level II evidence). View the reference
      8. Kumar AR, Katz PO. Functional esophageal disorders: a review of diagnosis and management. Expert Rev Gastroenterol Hepatol. 2013;7(5):453-61. (Review article). View the reference
      9. Jones D, Prowse S. Globus pharyngeus: an update for general practice. The British journal of general practice : the journal of the Royal College of General Practitioners. 2015;65(639):554-5. (Review). View the reference
      10. Cooper GS. Indications and contraindications for upper gastrointestinal endoscopy. Gastrointest Endosc Clin N Am. 1994;4(3):439-54. (Review article). View the reference
      11. Esfandyari T, Potter JW, Vaezi MF. Dysphagia: a cost analysis of the diagnostic approach. Am J Gastroenterol. 2002;97(11):2733-7. (Level III evidence). View the reference
      12. Varadarajulu S, Eloubeidi MA, Patel RS, Mulcahy HE, Barkun A, Jowell P, et al. The yield and the predictors of esophageal pathology when upper endoscopy is used for the initial evaluation of dysphagia. Gastrointest Endosc. 2005;61(7):804-8. (Level III evidence). View the reference
      13. Halpert RD, Feczko PJ, Spickler EM, Ackerman LV. Radiological assessment of dysphagia with endoscopic correlation. Radiology. 1985;157(3):599-602. (Level II evidence). View the reference
      14. Dooley CP, Larson AW, Stace NH, Renner IG, Valenzuela JE, Eliasoph J, et al. Double-contrast barium meal and upper gastrointestinal endoscopy. A comparative study. Ann Intern Med. 1984;101(4):538-45. (Level I evidence). View the reference
      15. Logemann JA. Role of the modified barium swallow in management of patients with dysphagia. Otolaryngol Head Neck Surg. 1997;116(3):335-8. (Review article). View the reference
      16. Parkman HP, Maurer AH, Caroline DF, Miller DL, Krevsky B, Fisher RS. Optimal evaluation of patients with nonobstructive esophageal dysphagia. Manometry, scintigraphy, or videoesophagography? Dig Dis Sci. 1996;41(7):1355-68. (Level II evidence). View the reference
      17. Schima W, Stacher G, Pokieser P, Uranitsch K, Nekahm D, Schober E, et al. Esophageal motor disorders: videofluoroscopic and manometric evaluation--prospective study in 88 symptomatic patients. Radiology. 1992;185(2):487-91. (Level II evidence). View the reference
      18. Ott DJ, Richter JE, Chen YM, Wu WC, Gelfand DW, Castell DO. Esophageal radiography and manometry: correlation in 172 patients with dysphagia. AJR Am J Roentgenol. 1987;149(2):307-11. (Level II evidence). View the reference
      19. Kelly S, Harris KM, Berry E, Hutton J, Roderick P, Cullingworth J, et al. A systematic review of the staging performance of endoscopic ultrasound in gastro-oesophageal carcinoma. Gut. 2001;49(4):534-9. (Level II evidence). View the reference
      20. Scharitzer M, Pokieser P, Schober E, Schima W, Eisenhuber E, Stadler A, et al. Morphological findings in dynamic swallowing studies of symptomatic patients. Eur Radiol. 2002;12(5):1139-44. (Level III evidence). View the reference
      21. Ramsey DJ, Smithard DG, Kalra L. Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke. 2003;34(5):1252-7. (Level III evidence). View the reference
      22. Barkhausen J, Goyen M, von Winterfeld F, Lauenstein T, Arweiler-Harbeck D, Debatin JF. Visualization of swallowing using real-time TrueFISP MR fluoroscopy. Eur Radiol. 2002;12(1):129-33. (Level III evidence). View the reference
      23. Giraldo-Cadavid LF, Leal-Leano LR, Leon-Basantes GA, Bastidas AR, Garcia R, Ovalle S, et al. Accuracy of endoscopic and videofluoroscopic evaluations of swallowing for oropharyngeal dysphagia. Laryngoscope. 2017;127(9):2002-10. (Level II evidence). View the reference
      24. Kahrilas PJ, Clouse RE, Hogan WJ. American Gastroenterological Association technical review on the clinical use of esophageal manometry. Gastroenterology. 1994;107(6):1865-84. (Evidence based guidelines). View the reference
      25. Feussner H, Kauer W, Siewert JR. The place of esophageal manometry in the diagnosis of dysphagia. Dysphagia. 1993;8(2):98-104. (Review article). View the reference
      26. Savarino E, de Bortoli N, Bellini M, Galeazzi F, Ribolsi M, Salvador R, et al. Practice guidelines on the use of esophageal manometry - A GISMAD-SIGE-AIGO medical position statement. Dig Liver Dis. 2016;48(10):1124-35. (Guideline). View the reference
      27. Yazaki E, Woodland P, Sifrim D. Uses of Esophageal Function Testing: Dysphagia. Gastrointest Endosc Clin N Am. 2014;24(4):643-54. (Review article). View the reference
      28. Tatsch K, Voderholzer WA, Weiss MJ, Schrottle W, Hahn K. Reappraisal of quantitative esophageal scintigraphy by optimizing results with ROC analyses. J Nucl Med. 1996;37(11):1799-805. (Level II evidence). View the reference

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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL RRL EFFECTIVE DOSE RANGE
No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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Gastrointestinal