Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Oesophageal dysphagia: manifestations and diagnosis

Key Points

  • An organic process must be ruled out by endoscopy in all patients presenting with dysphagia symptoms

  • Eosinophilic oesophagitis is one of the most prevalent causes of dysphagia in adults and children

  • Oesophageal biopsy samples should be obtained in all patients with unexplained dysphagia symptoms

  • High-resolution manometry is the gold-standard investigation for diagnosis of oesophageal motor disorders

  • According to the Chicago classification algorithm, major oesophageal motor disorders are achalasia, oesophagogastric junction outflow obstruction, diffuse oesophageal spasm, hypercontractile 'jackhammer' oesophagus and absent peristalsis

  • Sophisticated investigations (for example integrated pressure impedance analysis and impedance planimetry) could reveal subtle abnormalities and help distinguish between neuromechanical dysfunction and functional dysphagia

Abstract

Oesophageal dysphagia is a common symptom, which might be related to severe oesophageal diseases such as carcinomas. Therefore, an organic process must be ruled out in the first instance by endoscopy in all patients presenting with dysphagia symptoms. The most prevalent obstructive aetiologies are oesophageal cancer, peptic strictures and eosinophilic oesophagitis. Eosinophilic oesophagitis is one of the most common causes of dysphagia in adults and children, thus justifying the need to obtain oesophageal biopsy samples from all patients presenting with unexplained dysphagia. With the advent of standardized high-resolution manometry and specific metrics to characterize oesophageal motility, the Chicago classification has become a gold-standard algorithm for manometric diagnosis of oesophageal motor disorders. In addition, sophisticated investigations and analysis methods that combine pressure and impedance measurement are currently in development. In the future, these techniques might be able to detect subtle pressure abnormalities during bolus transport, which could further explain pathophysiology and symptoms. The degree to which novel approaches will help distinguish dysphagia caused by motor abnormalities from functional dysphagia still needs to be determined.

This is a preview of subscription content

Access options

Figure 1: Endoscopic features of dysphagia.
Figure 2: Oesophageal pressure topography Clouse plots of a normal water swallow on high-resolution manometry.
Figure 3: Impedance planimetry to assess distensibility of the oesophagus and EGJ.
Figure 4: Flow diagram illustrating the hierarchical analysis of patient EPT findings according to the Chicago classification.20
Figure 5: Examples of major oesophageal motility disorders never seen in healthy individuals.
Figure 6: Diagnosis algorithm for oesophageal dysphagia.

References

  1. Eslick, G. D. & Talley, N. J. Dysphagia: epidemiology, risk factors and impact on quality of life—a population-based study. Aliment. Pharmacol. Ther. 27, 971–979 (2008).

    CAS  Article  PubMed  Google Scholar 

  2. Lindgren, S. & Janzon, L. Prevalence of swallowing complaints and clinical findings among 50–79 year-old men and women in an urban population. Dysphagia 6, 187–192 (1991).

    CAS  Article  PubMed  Google Scholar 

  3. Galmiche, J. P. et al. Functional esophageal disorders. Gastroenterology 130, 1459–1465 (2006).

    Article  PubMed  Google Scholar 

  4. Roeder, B. E., Murray, J. A. & Dierkhising, R. A. Patient localization of esophageal dysphagia. Dig. Dis. Sci. 49, 697–701 (2004).

    Article  PubMed  Google Scholar 

  5. Chen, C. L. & Orr, W. C. Comparison of esophageal motility in patients with solid dysphagia and mixed dysphagia. Dysphagia 20, 261–265 (2005).

    Article  PubMed  Google Scholar 

  6. Zografos, G. N., Georgiadou, D., Thomas, D., Kaltsas, G. & Digalakis, M. Drug-induced esophagitis. Dis. Esophagus 22, 633–637 (2009).

    CAS  Article  PubMed  Google Scholar 

  7. Dellon, E. S. et al. ACG clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Am. J. Gastroenterol. 108, 679–692 (2013).

    Article  PubMed  Google Scholar 

  8. Belafsky, P. C. et al. Validity and reliability of the eating assessment tool (EAT-10). Ann. Otol. Rhinol. Laryngol. 117, 919–924 (2008).

    Article  PubMed  Google Scholar 

  9. McElhiney, J. et al. The mayo dysphagia questionnaire-30: documentation of reliability and validity of a tool for interventional trials in adults with esophageal disease. Dysphagia 25, 221–230 (2010).

    Article  PubMed  Google Scholar 

  10. Rommel, N., De Meyer, A. M., Feenstra, L. & Veereman-Wauters, G. The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. J. Pediatr. Gastroenterol. Nutr. 37, 75–84 (2003).

    Article  PubMed  Google Scholar 

  11. Singendonk, M. M., Rommel, N., Omari, T. I., Benninga, M. A. & van Wijk, M. P. Upper gastrointestinal motility: prenatal development and problems in infancy. Nat. Rev. Gastroenterol. Hepatol. 11, 545–555 (2014).

    Article  PubMed  Google Scholar 

  12. Muller, M. et al. Is the Schatzki ring a unique esophageal entity? World J. Gastroenterol. 17, 2838–2843 (2011).

    PubMed  PubMed Central  Google Scholar 

  13. Hirano, I. et al. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut 62, 489–495 (2013).

    Article  PubMed  Google Scholar 

  14. Muller, S., Puhl, S., Vieth, M. & Stolte, M. Analysis of symptoms and endoscopic findings in 117 patients with histological diagnoses of eosinophilic esophagitis. Endoscopy 39, 339–344 (2007).

    CAS  Article  PubMed  Google Scholar 

  15. Ponsot, P. et al. Chronic esophagitis dissecans: an unrecognized clinicopathologic entity? Gastrointest. Endosc. 45, 38–45 (1997).

    CAS  Article  PubMed  Google Scholar 

  16. Hokama, A. et al. Esophagitis dissecans superficialis and autoimmune bullous dermatoses: A review. World J. Gastrointest. Endosc. 2, 252–256 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  17. Katzka, D. A. et al. Variations in presentations of esophageal involvement in lichen planus. Clin. Gastroenterol. Hepatol. 8, 777–782 (2010).

    Article  PubMed  Google Scholar 

  18. Vaezi, M. F., Baker, M. E., Achkar, E. & Richter, J. E. Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment. Gut 50, 765–770 (2002).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  19. Vaezi, M. F., Baker, M. E. & Richter, J. E. Assessment of esophageal emptying post-pneumatic dilation: use of the timed barium esophagram. Am. J. Gastroenterol. 94, 1802–1807 (1999).

    CAS  Article  PubMed  Google Scholar 

  20. Bredenoord, A. J. et al. Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography. Neurogastroenterol. Motil. 24 (Suppl. 1), 57–65 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  21. Pandolfino, J. E., Kwiatek, M. A., Ho, K., Scherer, J. R. & Kahrilas, P. J. Unique features of esophagogastric junction pressure topography in hiatus hernia patients with dysphagia. Surgery 147, 57–64 (2010).

    Article  PubMed  Google Scholar 

  22. Kahrilas, P. J. & Peters, J. H. Evaluation of the esophagogastric junction using high resolution manometry and esophageal pressure topography. Neurogastroenterol. Motil. 24 (Suppl. 1), 11–19 (2012).

    Article  PubMed  Google Scholar 

  23. Xiao, Y. et al. Lack of correlation between HRM metrics and symptoms during the manometric protocol. Am. J. Gastroenterol. 109, 521–526 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  24. Daum, C. et al. Failure to respond to physiologic challenge characterizes esophageal motility in erosive gastro-esophageal reflux disease. Neurogastroenterol. Motil. 23, 517–e200 (2011).

    CAS  Article  PubMed  Google Scholar 

  25. Sweis, R. et al. Normative values and inter-observer agreement for liquid and solid bolus swallows in upright and supine positions as assessed by esophageal high-resolution manometry. Neurogastroenterol. Motil. 23, 509–e198 (2011).

    CAS  Article  PubMed  Google Scholar 

  26. Singendonk, M. M. J. et al. Applying the Chicago Classification criteria of esophageal motility to a pediatric cohort: effects of patient age and size. Neurogastroenterol. Motil. 26, 1333–1341 (2014).

    CAS  Article  PubMed  Google Scholar 

  27. Chumpitazi, B. & Nurko, S. Pediatric gastrointestinal motility disorders: challenges and a clinical update. Gastroenterol. Hepatol. (N.Y.) 4, 140–148 (2008).

    Google Scholar 

  28. Fox, M. et al. High-resolution manometry predicts the success of oesophageal bolus transport and identifies clinically important abnormalities not detected by conventional manometry. Neurogastroenterol. Motil. 16, 533–542 (2004).

    CAS  Article  PubMed  Google Scholar 

  29. Omari, T., Tack, J. & Rommel, N. Impedance as an adjunct to manometric testing: What it has failed to do and what it may tell us in the future. United European Gastroenterol. J. 2, 355–366 (2014).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  30. Omari, T., Kritas, S. & Cock, C. New insights into pharyngo-esophageal bolus transport revealed by pressure-impedance measurement. Neurogastroenterol. Motil. 24, 549–556 (2012).

    Article  Google Scholar 

  31. Imam, H., Marrero, F. & Shay, S. Impedance nadir values correlate with barium bolus amount. Dis. Esophagus 25, 600–607 (2012).

    CAS  Article  PubMed  Google Scholar 

  32. Kim, J. H., Mittal, R. K., Patel, N., Ledgerwood, M. & Bhargava, V. Esophageal distension during bolus transport: can it be detected by intraluminal impedance recordings? Neurogastroenterol. Motil. 26, 1122–1130 (2014).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  33. Omari, T. I. et al. Upper esophageal sphincter impedance as a marker of sphincter opening diameter. Am. J. Physiol. Gastrointest. Liver Physiol. 302, 909–913 (2012).

    Article  Google Scholar 

  34. Lin, Z. et al. Flow time through esophagogastric junction derived during high-resolution impedance-manometry studies: a novel parameter for assessing esophageal bolus transit. Am. J. Physiol. Gastrointest. Liver Physiol. 307, 158–163 (2014).

    Article  Google Scholar 

  35. Omari, T. I., Wauters, L., Rommel, N., Kritas, S. & Myers, J. C. Oesophageal pressure-flow metrics in relation to bolus volume, bolus consistency, and bolus perception. United European Gastroenterol. J. 1, 249–258 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  36. Chen, C. L., Yi, C. H., Liu, T. T., Hsu, C. S. & Omari, T. I. Characterization of esophageal pressure-flow abnormalities in patients with non-obstructive dysphagia and normal manometry findings. J. Gastroenterol. Hepatol. 28, 946–953 (2013).

    Article  PubMed  Google Scholar 

  37. Cho, Y. K. et al. Assessing bolus retention in achalasia using high-resolution manometry with impedance: a comparator study with timed barium esophagram. Am. J. Gastroenterol. 109, 829–835 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  38. Conchillo, J. M., Selimah, M., Bredenoord, A. J., Samsom, M. & Smout, A. J. Assessment of oesophageal emptying in achalasia patients by intraluminal impedance monitoring. Neurogastroenterol. Motil. 18, 971–977 (2006).

    CAS  Article  PubMed  Google Scholar 

  39. Rohof, W. O., Hirsch, D. P., Kessing, B. F. & Boeckxstaens, G. E. Efficacy of treatment for patients with achalasia depends on the distensibility of the esophagogastric junction. Gastroenterology 143, 328–335 (2012).

    Article  PubMed  Google Scholar 

  40. Nicodeme, F. et al. Esophageal distensibility as a measure of disease severity in patients with eosinophilic esophagitis. Clin. Gastroenterol. Hepatol. 11, 1101–1107 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  41. Gregersen, H., Kwiatek, M. A., Schwizer, W. & Tutuian, R. Contribution of sensitivity, volume and tone to visceral perception in the upper gastrointestinal tract in man: emphasis on testing. Neurogastroenterol. Motil. 19, 47–61 (2007).

    CAS  Article  PubMed  Google Scholar 

  42. Lin, Z. et al. Regional variation in distal esophagus distensibility assessed using the functional luminal imaging probe (FLIP). Neurogastroenterol. Motil. 25, 765–771 (2013).

    Article  Google Scholar 

  43. Vakil, N., van Zanten, S. V., Kahrilas, P., Dent, J. & Jones, R. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am. J. Gastroenterol. 101, 1900–1920 (2006).

    Article  PubMed  Google Scholar 

  44. Armstrong, D. et al. The endoscopic assessment of esophagitis: a progress report on observer agreement. Gastroenterology 111, 85–92 (1996).

    CAS  Article  PubMed  Google Scholar 

  45. Vakil, N. B., Traxler, B. & Levine, D. Dysphagia in patients with erosive esophagitis: prevalence, severity, and response to proton pump inhibitor treatment. Clin. Gastroenterol. Hepatol. 2, 665–668 (2004).

    CAS  Article  PubMed  Google Scholar 

  46. Rubenstein, J. H. & Taylor, J. B. Meta-analysis: the association of oesophageal adenocarcinoma with symptoms of gastro-oesophageal reflux. Aliment. Pharmacol. Ther. 32, 1222–1227 (2010).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  47. Fransen, G. A., Janssen, M. J., Muris, J. W., Laheij, R. J. & Jansen, J. B. Meta-analysis: the diagnostic value of alarm symptoms for upper gastrointestinal malignancy. Aliment. Pharmacol. Ther. 20, 1045–1052 (2004).

    CAS  Article  PubMed  Google Scholar 

  48. El-Serag, H. B. & Lau, M. Temporal trends in new and recurrent oesophageal strictures in a Medicare population. Aliment. Pharmacol. Ther. 25, 1223–1229 (2007).

    CAS  Article  PubMed  Google Scholar 

  49. Savarino, E. et al. Oesophageal motility and bolus transit abnormalities increase in parallel with the severity of gastro-oesophageal reflux disease. Aliment. Pharmacol. Ther. 34, 476–486 (2011).

    CAS  Article  PubMed  Google Scholar 

  50. Broeders, J. A. et al. Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease. Br. J. Surg. 97, 1318–1330 (2010).

    CAS  Article  PubMed  Google Scholar 

  51. Galmiche, J. P. et al. Laparoscopic antireflux surgery vs esomeprazole treatment for chronic GERD: the LOTUS randomized clinical trial. JAMA 305, 1969–1977 (2011).

    CAS  Article  PubMed  Google Scholar 

  52. Loots, C. et al. Gastroesophageal reflux, esophageal function, gastric emptying, and the relationship to dysphagia before and after antireflux surgery in children. J. Pediatr. 162, 566–573 (2013).

    Article  PubMed  Google Scholar 

  53. Myers, J. C. et al. Susceptibility to dysphagia after fundoplication revealed by novel automated impedance manometry analysis. Neurogastroenterol. Motil. 24, 812–e393 (2012).

    CAS  Article  PubMed  Google Scholar 

  54. Stoikes, N. et al. The value of multiple rapid swallows during preoperative esophageal manometry before laparoscopic antireflux surgery. Surg. Endosc. 26, 3401–3407 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  55. Kidambi, T., Toto, E., Ho, N., Taft, T. & Hirano, I. Temporal trends in the relative prevalence of dysphagia etiologies from 1999–2009. World J. Gastroenterol. 18, 4335–4341 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  56. Syed, A. A. et al. The rising incidence of eosinophilic oesophagitis is associated with increasing biopsy rates: a population-based study. Aliment. Pharmacol. Ther. 36, 950–958 (2012).

    CAS  Article  PubMed  Google Scholar 

  57. Rothenberg, M. E. et al. Common variants at 5q22 associate with pediatric eosinophilic esophagitis. Nat. Genet. 42, 289–291 (2010).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  58. Gonsalves, N. et al. Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology 142, 1451–1459 (2012).

    Article  PubMed  Google Scholar 

  59. Lucendo, A. J. et al. Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease. J. Allergy Clin. Immunol. 131, 797–804 (2013).

    Article  PubMed  Google Scholar 

  60. Molina-Infante, J. et al. Esophageal eosinophilic infiltration responds to proton pump inhibition in most adults. Clin. Gastroenterol. Hepatol. 9, 110–117 (2011).

    CAS  Article  PubMed  Google Scholar 

  61. van Rhijn, B. D. et al. Proton pump inhibitors partially restore mucosal integrity in patients with proton pump inhibitor-responsive esophageal eosinophilia but not eosinophilic esophagitis. Clin. Gastroenterol. Hepatol. 12, 1815–1823 (2014).

    CAS  Article  PubMed  Google Scholar 

  62. Roman, S. et al. Manometric features of eosinophilic esophagitis in esophageal pressure topography. Neurogastroenterol. Motil. 23, 208–214 (2011).

    CAS  Article  PubMed  Google Scholar 

  63. Kwiatek, M. A. et al. Mechanical properties of the esophagus in eosinophilic esophagitis. Gastroenterology 140, 82–90 (2011).

    Article  PubMed  Google Scholar 

  64. van Rhijn, B. D., Verheij, J., Smout, A. J. & Bredenoord, A. J. Rapidly increasing incidence of eosinophilic esophagitis in a large cohort. Neurogastroenterol. Motil. 25, 47–52 (2013).

    CAS  Article  PubMed  Google Scholar 

  65. Furuta, G. T. et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology 133, 1342–1363 (2007).

    CAS  Article  PubMed  Google Scholar 

  66. Desai, T. K. et al. Association of eosinophilic inflammation with esophageal food impaction in adults. Gastrointest. Endosc. 61, 795–801 (2005).

    Article  PubMed  Google Scholar 

  67. Carlson, D. A. & Pandolfino, J. E. The Chicago criteria for esophageal motility disorders: what has changed in the past 5 years? Curr. Opin. Gastroenterol. 28, 395–402 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  68. Kahrilas, P. J. Esophageal motor disorders in terms of high-resolution esophageal pressure topography: what has changed? Am. J. Gastroenterol. 105, 981–987 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  69. Kahrilas, P. J. & Boeckxstaens, G. The spectrum of achalasia: lessons from studies of pathophysiology and high-resolution manometry. Gastroenterology 145, 954–965 (2013).

    Article  PubMed  Google Scholar 

  70. Pandolfino, J. E. et al. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 135, 1526–1533 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  71. Nicodeme, F. et al. Adding a radial dimension to the assessment of esophagogastric junction relaxation: validation studies of the 3D-eSleeve. Am. J. Physiol. Gastrointest. Liver Physiol. 303, 275–280 (2012).

    Article  Google Scholar 

  72. Bogte, A., Bredenoord, A. J., Oors, J., Siersema, P. D. & Smout, A. J. Relationship between esophageal contraction patterns and clearance of swallowed liquid and solid boluses in healthy controls and patients with dysphagia. Neurogastroenterol. Motil. 24, 364–372 (2012).

    Article  Google Scholar 

  73. Sweis, R., Anggiansah, A., Wong, T., Brady, G. & Fox, M. Assessment of esophageal dysfunction and symptoms during and after a standardized test meal: development and clinical validation of a new methodology utilizing high-resolution manometry. Neurogastroenterol. Motil. 26, 215–228 (2014).

    CAS  Article  PubMed  Google Scholar 

  74. Nguyen, N. Q., Holloway, R. H., Smout, A. J. & Omari, T. I. Automated impedance-manometry analysis detects esophageal motor dysfunction in patients who have non-obstructive dysphagia with normal manometry. Neurogastroenterol. Motil. 25, 238–245 (2013).

    CAS  Article  PubMed  Google Scholar 

  75. Rommel, N., Van Oudenhove, L., Tack, J. & Omari, T. I. Automated impedance manometry analysis as a method to assess esophageal function. Neurogastroenterol. Motil. 26, 636–645 (2014).

    CAS  Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Contributions

Both authors contributed equally to all aspects of this manuscript.

Corresponding author

Correspondence to Frank Zerbib.

Ethics declarations

Competing interests

F.Z. is a consultant and speaker for Given Imaging. T.O. holds patents on pressure-flow analysis methods.

PowerPoint slides

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Zerbib, F., Omari, T. Oesophageal dysphagia: manifestations and diagnosis. Nat Rev Gastroenterol Hepatol 12, 322–331 (2015). https://doi.org/10.1038/nrgastro.2014.195

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrgastro.2014.195

Further reading

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing