Dysphagia, or difficulty swallowing, is a symptom that can be caused by various surgical
conditions affecting the oral cavity, pharynx, and esophagus. It's a critical symptom that, when
persistent, requires thorough investigation to rule out serious underlying pathology.
Surgical Causes of Dysphagia
Dysphagia can be caused by conditions that mechanically obstruct the passage of food or affect
the function of the swallowing muscles. Surgical causes include both benign and malignant
conditions, as well as complications from previous surgeries.
● Benign Causes
○ Achalasia: A motor disorder where the lower esophageal sphincter (LES) fails to
relax and there is a loss of peristalsis in the esophagus. This leads to food
accumulation and a "bird's beak" appearance on a barium swallow.
○ Esophageal strictures: Narrowing of the esophagus, often caused by
long-standing gastroesophageal reflux disease (GERD) leading to peptic strictures,
or from corrosive injury, radiation therapy, or iatrogenic injury (e.g., from
endoscopy).
○ Pharyngeal pouches (Zenker's diverticulum): A herniation of the pharyngeal
mucosa through a weak point in the muscle wall (Killian's triangle), causing a pouch
that can trap food and lead to regurgitation of undigested food.
○ Esophageal webs and rings: Thin, diaphragm-like membranes of tissue that can
form in the esophagus, most commonly at the gastroesophageal junction (Schatzki
ring). They typically cause dysphagia for solids.
○ Post-surgical complications: Dysphagia can occur after surgeries on the head
and neck, esophagus, or stomach due to nerve damage, scar tissue formation, or
anatomical changes. Examples include post-laryngectomy, esophagectomy with
gastric pull-up, or Nissen fundoplication for GERD.
● Malignant Causes
○ Carcinoma of the esophagus: This is the most common malignant cause of
progressive dysphagia in adults. The tumor grows to obstruct the esophageal
lumen.
○ Carcinoma of the head and neck: Tumors in the oral cavity, pharynx, or larynx
can interfere with the oral and pharyngeal phases of swallowing.
○ Extrinsic compression: Tumors in nearby structures, such as lung cancer or
mediastinal lymphadenopathy, can press on the esophagus, causing dysphagia.
Presentation and Evaluation
The presentation of dysphagia depends on the underlying cause.
● History: A detailed history is crucial. Key questions include:
○ Onset and progression: Is it sudden or gradual? Is it progressing (getting worse)?
Progressive dysphagia for solids, then liquids, is a classic sign of mechanical
obstruction, particularly malignancy.
○ Nature of dysphagia: Is it for solids, liquids, or both? Dysphagia for solids alone
suggests a mechanical obstruction, while dysphagia for both solids and liquids from
the outset suggests a motility disorder.
○ Associated symptoms: * Odynophagia: Painful swallowing, suggesting
inflammation, ulceration, or infection.
■ Weight loss: A red flag for malignancy.
■ Regurgitation: Bringing up undigested food, common in achalasia and
Zenker's diverticulum.
■ Hoarseness or coughing: May indicate aspiration or nerve involvement
(e.g., recurrent laryngeal nerve in esophageal cancer).
■ Heartburn or chest pain: May be related to GERD, a risk factor for strictures
and esophageal cancer.
● Investigation:
○ Barium swallow (Esophagogram): A simple and non-invasive initial test to
visualize the esophageal anatomy and function. It can identify strictures, webs,
tumors, and motility disorders like achalasia.
○ Upper gastrointestinal endoscopy: The gold standard for direct visualization of
the esophagus. It allows for biopsy of suspicious lesions to obtain a definitive
diagnosis, and for therapeutic interventions like dilation of strictures.
○ Manometry: A test to measure the pressures and contractions of the esophageal
muscles. It's essential for diagnosing motility disorders like achalasia.
○ CT scan: Used to stage a malignancy by assessing the extent of the primary tumor,
and looking for involvement of nearby lymph nodes or distant metastases.
Esophageal Cancer (Ca Esophagus)
Esophageal cancer is a major cause of progressive dysphagia and is a highly malignant tumor.
● Pathology: The two main histological types are:
○ Squamous cell carcinoma: More common in the upper and middle esophagus.
Risk factors include smoking, alcohol, and hot food/drinks.
○ Adenocarcinoma: More common in the distal esophagus and gastroesophageal
junction. It's strongly linked to Barrett's esophagus, a metaplastic change caused
by chronic GERD.
● Staging: The TNM (Tumor, Node, Metastasis) staging system is used to determine the
extent of the disease and guide treatment. Key staging tools include endoscopy with
biopsy, endoscopic ultrasound (EUS) for local staging and lymph node assessment, and a
CT scan of the chest and abdomen for distant metastases.
● Management: Management is complex and depends on the stage of the cancer. A
multidisciplinary team approach is essential.
○ Early-stage (T1N0M0): Tumors confined to the superficial layers of the esophagus
can be treated with endoscopic mucosal resection (EMR) or endoscopic
submucosal dissection (ESD).
○ Locally advanced (T1-4, N0-3, M0): The standard of care is neoadjuvant therapy
(chemotherapy, or chemoradiotherapy) followed by esophagectomy.
■ Esophagectomy: The surgical removal of part or all of the esophagus, with
the remaining part connected to a substitute conduit, most commonly the
stomach ("gastric pull-up"). Different surgical approaches exist (e.g., Ivor
Lewis, McKeown, or transhiatal).
■ Minimally invasive esophagectomy (MIE): A less invasive approach using
laparoscopy and thoracoscopy, which can lead to faster recovery and fewer
complications.
○ Palliative management (metastatic or unresectable disease): The goal is to
relieve dysphagia and improve quality of life. Options include:
■ Self-expanding metal stents (SEMS): To hold the esophagus open.
■ Radiation therapy or chemotherapy: To shrink the tumor.
■ Laser ablation: To debulk the tumor.
■ Nutritional support: Placement of a gastrostomy or jejunostomy tube.
