dysphagia

First distinguish oropharyngeal from oesophageal dysphagia by history — the localisation and pattern narrow the differential quickly. Oropharyngeal dysphagia is usually neuromuscular → videofluoroscopic swallow study (VFSS). Oesophageal dysphagia to solids only suggests mechanical obstruction → EGD first. Dysphagia to both solids and liquids from onset suggests a motility disorder → EGD then high-resolution manometry (HRM). Achalasia is the motility disorder you cannot miss.

classification

flowchart TD
    A["Dysphagia"] --> B{"Difficulty initiating<br/>swallow? Food sticks<br/>in throat/nasal regurg?"}
    B -->|Yes| C["Oropharyngeal"]
    B -->|No — food sticks<br/>in chest/epigastrium| D["Oesophageal"]
    C --> E["VFSS ± ENT/neuro<br/>referral"]
    D --> F{"Solids only<br/>or solids + liquids?"}
    F -->|Solids only<br/>progressive| G["Mechanical obstruction<br/>→ EGD"]
    F -->|Solids + liquids<br/>from onset| H["Motility disorder<br/>→ EGD then HRM"]
    G --> G1["Stricture<br/>Schatzki ring<br/>Eosinophilic oesophagitis<br/>Malignancy"]
    H --> H1["Achalasia<br/>Distal oesophageal spasm<br/>Jackhammer oesophagus<br/>Absent contractility"]

oropharyngeal dysphagia

Difficulty initiating the swallow — coughing, choking, nasal regurgitation, wet voice.

cause	clues
stroke / neurological	acute onset, focal neuro signs, known CVA/PD/ALS/MS
Parkinson’s disease	progressive, tremor, rigidity
myasthenia gravis	fatigable, worse with repeated swallowing, ptosis
Zenker’s diverticulum	halitosis, regurgitation of undigested food, neck gurgling
head/neck malignancy or radiation	odynophagia, weight loss, prior radiation
oropharyngeal candidiasis	immunosuppression, steroid inhaler use

Workup: VFSS (videofluoroscopic swallow study) is the initial test — evaluates pharyngeal mechanics and aspiration risk. ENT and/or neurology referral as directed by findings.

oesophageal dysphagia — mechanical

Progressive dysphagia to solids → then liquids as obstruction worsens. EGD is the first test — diagnostic and therapeutic.

cause	EGD findings / clues
peptic stricture	smooth, concentric narrowing at GOJ; chronic GERD history
Schatzki ring	thin mucosal ring at squamocolumnar junction; intermittent solid food dysphagia (“steakhouse syndrome”)
eosinophilic oesophagitis	rings, furrows, exudates, stricture; young male, atopy; biopsy ≥15 eos/hpf
oesophageal malignancy	irregular mass/ulcer, weight loss, progressive; biopsy
extrinsic compression	smooth indentation — mediastinal mass, vascular (dysphagia lusoria), LAD

food bolus impaction

Acute solid food impaction → urgent EGD within 6 hours (aspiration risk with complete obstruction). After disimpaction, biopsy the oesophagus — eosinophilic oesophagitis is the most common underlying cause in young adults.

oesophageal dysphagia — motility disorders

Dysphagia to solids and liquids from the outset. EGD first to exclude mechanical obstruction → if normal, high-resolution manometry (HRM) is the definitive test.

Chicago Classification v4.0 — key disorders

disorder	HRM pattern	management
achalasia type I	absent peristalsis, elevated IRP	POEM or laparoscopic Heller myotomy (LHM)
achalasia type II	pan-oesophageal pressurisation, elevated IRP	best prognosis; POEM or LHM
achalasia type III	spastic contractions, elevated IRP	POEM preferred (longer myotomy)
distal oesophageal spasm (DES)	≥20% premature contractions, normal IRP	PPI, neuromodulators (TCA, trazodone), smooth muscle relaxants
hypercontractile (Jackhammer)	DCI >8000 mmHg·cm·s	exclude opioids, obstruction; PPI trial, neuromodulators
absent contractility	100% failed peristalsis, normal IRP	exclude scleroderma; anti-reflux precautions (no fundoplication)

achalasia — details

Failure of lower oesophageal sphincter (LOS) relaxation + absent/disordered peristalsis from loss of inhibitory ganglion cells in the myenteric plexus.

Red flags for pseudoachalasia (malignant infiltration mimicking achalasia):

Age >55 with rapid onset (<6 months)
Significant weight loss
Difficult scope passage through GOJ
CT/EUS to exclude GOJ or fundal malignancy

Treatment hierarchy:

Definitive: POEM or laparoscopic Heller myotomy + partial fundoplication (Dor/Toupet) — equivalent efficacy at 2 years; POEM has higher post-procedure GERD rates
Moderate risk / bridging: pneumatic dilation (graded, 30→35 mm)
Unfit for intervention: botulinum toxin injection (temporary, 6–12 months)

achalasia and oesophageal cancer

Long-standing achalasia increases squamous cell carcinoma risk (~30-fold). No consensus on surveillance — some centres offer EGD every 3–5 years after 10–15 years of disease. Maintain a low threshold for EGD with new symptoms.

common traps

Assuming all dysphagia needs EGD first — oropharyngeal dysphagia needs VFSS, not endoscopy
Missing eosinophilic oesophagitis — always biopsy a normal-appearing oesophagus in young patients with solid food dysphagia or food impaction
Treating achalasia with PPI — elevated IRP means the sphincter is not relaxing; acid suppression does not address the problem
Forgetting pseudoachalasia — new-onset achalasia pattern in an older patient with weight loss mandates CT/EUS before definitive myotomy
Fundoplication in absent contractility — wrapping a tube with no peristalsis causes severe dysphagia; these patients need anti-reflux lifestyle measures only