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CBC (if anemia or infection are suspected)

Liver-associated enzymes/right upper quadrant ultrasound (if hepatobiliary disease is suspected)

Pancreatic enzymes (if pancreatic disease is suspected)

Upper endoscopy for patients ≥60 to rule out malignancy (4)[C]

Upper endoscopy is unlikely to change outcomes or management (5)[C].

Self-report questionnaires can track symptoms (3)[C].

Diagnostic Procedures/Other

Esophageal manometry or gastric accommodation studies are rarely needed (3)[C].

Motility studies are unnecessary, unless gastroparesis is strongly suspected (4) [C].

Test Interpretation

None (by definition, this a functional disorder)

TREATMENT

GENERALMEASURES

Reassurance and physician support are helpful (2,3)[C].

Treatment is based on presumed etiologies.

Discontinue offending medications (3)[C].

Routine endoscopy not recommended in dyspeptic patients <60 years even with alarm features (4)[B]

MEDICATION

First Line

Treat H. pylori if confirmed on testing (3,4)[A].

Trial of once daily proton pump inhibitor (PPI) medication (e.g., omeprazole 20 mg PO QD) or H2RA(e.g., ranitidine 150 mg BID) for up to 8 weeks in patients without alarm symptoms. This is most effective in EPS (3–5)[A].

Prokinetics have been proposed as first-line agents in PDS, although efficacy data for metoclopramide (only agent approved in United States) are limited (5)[C]. Prokinetics should be prescribed at the lowest effective dose to avoid potential side effects (4)[C]. Use with caution in elderly patients due to side effects of tardive dyskinesia and parkinsonian symptoms.

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Second Line

Trial of tricyclic antidepressant (TCA) medication is more helpful for EPS than PDS (e.g., amitriptyline 25 mg PO QD, can up-titrate to 50 mg PO QD), with a NNT of 6 (2,4–6)[A]. Caution in elderly. There is no benefit to SSRI/SNRI (6)[A].

Trazodone 25 mg at bedtime is an alternative (2,5)[A]. Consider buspirone or mirtazapine if no response or if contraindications to TCA(2)[B].

ADDITIONALTHERAPIES

Stress reduction (2,5)[C]

Psychotherapy effective in some patients (2)[C],(3,4)[B]

Patients should be given a positive diagnosis and reassured of benign prognosis (2)[C].

COMPLEMENTARY& ALTERNATIVE MEDICINE

Alternative medicine approaches need further study and are not currently recommended (4)[C].

Iberogast may be helpful (2)[C].

Probiotics have theoretical benefit but few controlled trials (2,5)[C].

Hypnotherapy may help (3)[B].

Transcutaneous electroacupuncture may help (3)[B].

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Provide ongoing support and reassurance.

Upper endoscopy if persistent symptoms

Change medications if no difference in symptoms after 4 weeks (3)[C].

Discontinue medications once symptoms resolve (3)[C].

DIET

Limited data to support dietary modification Consider limiting fatty foods (2,5)[C].

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Avoid foods that exacerbate symptoms: wheat and cow milk proteins, peppers or spices, coffee, tea, and alcohol (2,5)[C].

PATIENT EDUCATION

Reassurance and stress reduction techniques

PROGNOSIS

Long-term/chronic symptoms with symptom-free periods

COMPLICATIONS

Iatrogenic, from evaluation to rule out serious pathology

REFERENCES

1.Stanghellini V, Chan FK, Hasler WL, et al. Gastroduodenal disorders. Gastroenterology. 2016;150(6):1380–1392.

2.Talley NJ, Ford AC. Functional dyspepsia. N Engl J Med. 2015;373(19):1853–1863.

3.Miwa H, Kusano M, Arisawa T, et al. Evidence-based clinical practice guidelines for functional dyspepsia. J Gastroenterol. 2015;50(2):125–139.

4.Moayedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterology. 2017;112(7):988–1013.

5.Talley NJ. Functional dyspepsia: new insights into pathogenesis and therapy. Korean J Intern Med. 2016;31(3):444–456.

6.Ford AC, Luthra P, Tack J, et al. Efficacy of psychotropic drugs in functional dyspepsia: systematic review and meta-analysis. Gut. 2017;66(3):411–420.

ADDITIONALREADING

Du LJ, Chen BR, Kim JJ, et al. Helicobacter pylori eradication therapy for functional dyspepsia: systematic review and meta-analysis. World J Gastroenterol. 2016;22(12):3486–3495.

Ford AC, Marwaha A, Sood R, et al. Global prevalence of, and risk factors for, uninvestigated dyspepsia: a meta-analysis. Gut. 2015;64(7):1049–1057.

Lu Y, Chen M, Huang Z, et al. Antidepressants in the treatment of functional dyspepsia: a systematic review and meta-analysis. PLoS One. 2016;11(6):e0157798.

Mahadeva S, Ford AC. Clinical and epidemiological differences in functional

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dyspepsia between the East and West. Neurogastroenterol Motil. 2016; 28(2):

167–174.

Talley NJ, Walker MM, Holtman G. Functional dyspepsia. Curr Opin Gastroenterol. 2016;32(6):467–473.

SEE ALSO

Irritable Bowel Syndrome

Algorithm: Dyspepsia

CODES

ICD10

K30 Functional dyspepsia

CLINICALPEARLS

Dyspepsia without underlying organic disease is functional or idiopathic.

Consider empiric acid suppression therapy as first line for functional dyspepsia.

Extensive diagnostic testing is not recommended unless alarm symptoms are present.

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DYSPHAGIA

Felix B. Chang, MD, DABMA, FAAMA

BASICS

Difficulty transmitting the alimentary bolus from the mouth to stomach

DESCRIPTION

Oropharyngeal dysphagia: difficulty transferring food bolus from oropharynx to proximal esophagus

Esophageal dysphagia: difficulty moving food bolus through the body of the esophagus to the pylorus

EPIDEMIOLOGY

10% of individuals >50 years of age

Prevalence

Common primary care complaint

Rates of impaired swallowing in nursing home residents range from 29% to 32%.

ETIOLOGYAND PATHOPHYSIOLOGY

Oropharyngeal (transfer dysphagia):

–Mechanical causes: pharyngeal and laryngeal cancer, acute epiglottitis, carotid body tumor, pharyngitis, tonsillitis, strep throat, lymphoid hyperplasia of lingual tonsil, lateral pharyngeal pouch, hypopharyngeal

diverticulum Esophageal:

–Esophageal mechanical lesions: carcinomas, esophageal diverticula, esophageal webs, Schatzki ring, structures (peptic, chemical, trauma, radiation), foreign body

–Extrinsic mechanical lesions: peritonsillar abscess, thyroid disorders, tumors, mediastinal compression, vascular compression (enlarged left atrium, aberrant subclavius, aortic aneurysm), osteoarthritis of the cervical spine, adenopathy, esophageal duplication cyst

Neuromuscular: achalasia, diffuse esophageal spasm, hypertonic lower esophageal sphincter, scleroderma, nutcracker esophagus, CVA, Alzheimer

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disease, Huntington chorea, Parkinson disease, multiple sclerosis, skeletal muscle disease (polymyositis, dermatomyositis), neuromuscular junction disease (myasthenia gravis, Lambert-Eaton syndrome, botulism), hyperand hypothyroidism, Guillain-Barré syndrome, systemic lupus erythematosus, acute lymphoblastic leukemia, amyloidosis, diabetic neuropathy, brainstem tumors, Chagas disease

Infection: diphtheria, chronic meningitis, tertiary syphilis, Lyme disease, rabies, poliomyelitis, CMV, esophagitis (Candida, herpetic)

Globus phenomenon

RISK FACTORS

Children: hereditary and/or congenital malformations

Adults: age >50 years; elderly: GERD, stroke, COPD, chronic pain

Smoking, excess alcohol intake, obesity

Medications: quinine, potassium chloride, vitamin C, tetracycline, Bactrim, clindamycin, NSAIDs, procainamide, anticholinergics, bisphosphates

Neurologic events or diseases: CVA, myasthenia gravis, multiple sclerosis, Parkinson disease, amyotrophic lateral sclerosis (ALS), Huntington chorea

HIV patients with CD4 cell count <100 cells/mm3

Trauma or irradiation of head, neck, and chest; mechanical lesions

Extrinsic mechanical lesions: lung, thyroid tumors, lymphoma, metastasis

Iron deficiency

Anterior cervical spine surgery (up to 71% in the first 2 weeks postop; 12– 14% at 1 year postop)

Dysphagia lusoria (vascular abnormalities causing dysphagia): complete vascular ring, double aortic arch, right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum, and right aortic arch with mirror-image branching and left ligamentum arteriosum

GENERALPREVENTION

Correct poorly fitting dentures.

Educate patients to prolong chewing and drink adequate volumes of water at meals.

Liquid and soft food diet as appropriate

Avoid alcohol with meals.

Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation

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COMMONLYASSOCIATED CONDITIONS

Peptic structure, esophageal webs and rings, carcinoma; history of stroke, dementia, pneumonia

DIAGNOSIS

HISTORY

Dysphagia to both solids and liquids from the onset of deglutition likely represents an esophageal motility disorder.

Oropharyngeal dysphagia presents as difficulty initiating the swallowing process.

Dysphagia for solids that progresses to involve liquids more likely reflects mechanical obstruction.

Progressive dysphagia is usually caused by cancer or a peptic stricture. Intermittent dysphagia is most often related to a lower esophageal ring.

Inquire about heartburn, weight loss, hematemesis, coffee ground emesis, anemia, regurgitation of undigested food particles, and respiratory symptoms.

Inquire about regurgitation, aspiration, or drooling immediately after swallowing as this may represent oropharyngeal dysphagia.

Does the food bolus feel stuck?

–Upper sternum or back of throat may represent oropharyngeal dysphagia, whereas sensation over the lower sternum is typical of esophageal

dysphagia.

Is odynophagia present?

– May represent inflammation, achalasia, diffuse esophageal spasm, esophagitis, pharyngitis, pill-induced esophagitis, cancer

Globus sensation (“lump in the throat”)?

– Potentially indicates cricopharyngeal or laryngeal disorders

History of sour taste in the back of the throat or chronic heartburn suggests GERD.

Inquire about alcohol and/or tobacco use.

Are there associated symptoms such as weight loss or chest pain?

–Double aortic arch, right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum

–Anticholinergics, antihistamines, and some antihypertensives can decrease salivary production.

Halitosis: Rule out diverticulitis.

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Prior history of a connective tissue disorder

Changes in speech, hoarseness, weak cough, dysphonia? Rule out neuromuscular dysfunction.

PHYSICALEXAM

General: vital signs

Skin: telangiectasia, sclerodactyly, calcinosis (r/o autoimmune disease); Raynaud phenomenon, sclerodactyly may be found in CREST syndrome or systemic scleroderma; stigmata of alcohol abuse (palmar erythema; telangiectasia)

Head, eye, ear, nose, throat (HEENT):

–Oropharyngeal: pharyngeal erythema/edema, tonsillitis, pharyngeal ulcers or thrush, odynophagia (bacterial, viral, fungal infections); tongue fasciculations (ALS)

–Neck: masses, lymphadenopathy, neck tenderness (thyroiditis), goiter

Neurologic:

–Cranial nerve exam: sensory: cranial nerves V, IX, and X; motor: cranial nerves V, VII, X, XI, and XII

–CNS, mental status exam, strength testing, Horner syndrome, ataxia, cogwheel rigidity (CVA, dementia, Parkinson disease, Alzheimer disease) Eye position, extraocular motility

Informal bedside swallowing evaluation: Observe level of consciousness, postural control-upright position, oral hygiene, mobilization of oral secretions.

DIFFERENTIALDIAGNOSIS

See “Etiology and Pathophysiology.”

DIAGNOSTIC TESTS & INTERPRETATION

Adults (1)[C]:

Barium swallow

Fiberoptic endoscopic examination of swallowing (FEES)

Gastroesophageal endoscopy

Barium cine/video esophagram

Ambulatory 24-hour pH testing

Esophageal manometry

Videofluoroscopic swallowing study (VFSS): oropharyngeal dysphagia

Initial Tests (lab, imaging)

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Guided by diagnostic considerations (2)[C]

–CBC (infection and inflammation)

–Serum protein and albumin levels for nutritional assessment

–Thyroid function studies to detect dysphagia associated with hypothyroidism or hyperthyroidism, cobalamin levels

–Antiacetylcholine antibodies (myasthenia)

Barium swallow: detects strictures or stenosis

Follow-Up Tests & Special Considerations

CT scan of chest; MRI of brain and cervical spine

VFSS (lips, tongue, palate, pharynx, larynx, proximal esophagus)

Fiberoptic endoscopy and videofluoroscopy are similar in terms of diagnostic sensitivity (3)[C].

Diagnostic Procedures/Other

Endoscopy with biopsy; esophageal manometry; esophageal pH monitoring

TREATMENT

GENERALMEASURES

Exclude cardiac disease. Ensure airway patency and adequate pulmonary function. Assess nutritional status. Speech therapy evaluation is helpful.

MEDICATION

First Line

For esophageal spasms: calcium channel blockers: nifedipine 10 to 30 mg TID; imipramine 50 mg at bedtime; sildenafil 50 mg/day PRN

For esophagitis:

–Antacids: Tums, Mylanta, Maalox

–H2 blockers:

Cimetidine: up to 1,600 mg orally per day in 2 or 4 divided doses for 12 weeks

Ranitidine: initial 150 mg orally 4 times daily and maintenance 150 mg orally twice daily

Nizatidine: 150 mg orally twice daily for 12 weeks

Famotidine: 20 to 40 mg orally twice daily for 12 weeks

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Proton pump inhibitors:

–Omeprazole: 20 mg once daily for 4 to 8 weeks

–Lansoprazole: 30 mg once daily for up to 8 weeks

–Rabeprazole: 20 mg orally once daily for 4 to 8 weeks

–Esomeprazole: 20 to 40 mg orally once daily for 4 to 8 weeks

–Pantoprazole: 40 mg orally once daily for up to 8 weeks

Prokinetic agents: rarely used

Precautions: may need to use liquid forms of medications because patients might have difficulty swallowing pills

ISSUES FOR REFERRAL

Gastroenterology: endoscopy, refractory symptoms

Surgery: dilation, esophageal myotomy, biopsy

ADDITIONALTHERAPIES

Speech therapy to assess swallowing; nutritional evaluation for dietary and positioning recommendations; physical therapy for muscle-strengthening exercise; no eating at bedtime; remaining upright after eating

Self-expanded metal stent is safe, effective, and quicker in palliating dysphagia compared to other modalities.

SURGERY/OTHER PROCEDURES

Esophageal dilatation (pneumatic or bougie)

Esophageal stent; laser for cancer palliation (4)[A]

Treat underlying problem (e.g., thyroid goiter, vascular ring, esophageal atresia).

Nd:YAG laser incision of lower esophageal rings refractory to dilation

Photodynamic therapy (cancer) (4)[C]

Cricopharyngeal myotomy (oropharyngeal dysphagia)

Surgery for Zenker diverticulum, refractory strictures, or myotomy (for achalasia)

Percutaneous endoscopic gastrostomy (PEG) decreases risk of dysphagia when compared with nasogastric tube.

COMPLEMENTARY& ALTERNATIVE MEDICINE

Acupuncture has been used with some success for neurogenic dysphagia. Electroacupuncture combined with dilating granule has been used in the

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