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Oesophageal dysphagia: manifestations and diagnosis

Nature Reviews Gastroenterology & Hepatology volume 12, pages 322–331 (2015)Cite this article

Subjects

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.

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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.

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Authors and Affiliations

  1. Gastroenterology and Hepatology Department, Saint André Hospital, Centre Hospitalier Universitaire de Bordeaux, 1 Rue Jean Burguet, Bordeaux, F-33075, France

    Frank Zerbib

  2. Medical Science and Technology, School of Medicine, Flinders University, Sturt Road, Bedford Park, 5042, SA, Australia

    Taher Omari

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Both authors contributed equally to all aspects of this manuscript.

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Correspondence to Frank Zerbib.

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

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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

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