ACR Appropriateness Criteria®
Clinical Condition: Dysphagia
Variant 1: Oropharyngeal dysphagia with an
attributable cause.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| Barium Studies |
Modified barium swallow |
8 |
|
Dynamic and static imaging of pharynx |
6 |
|
Biphasic esophagram (double contrast and single contrast) |
4 |
|
Single contrast esophagram |
4 |
|
| Endoscopy |
4 |
|
| Esophageal manometry |
4 |
|
| Radionuclide esophageal transit scintigraphy |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 2: Unexplained oropharyngeal dysphagia.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| Barium Studies |
Dynamic and static imaging of pharynx |
8 |
|
Biphasic esophagram (double contrast and single contrast) |
8 |
|
Modified barium swallow |
6 |
|
Single contrast esophagram |
6 |
|
| Endoscopy |
4 |
|
| Esophageal manometry |
4 |
|
| Radionuclide esophageal transit scintigraphy |
4 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 3: Substernal dysphagia in immunocompetent patients.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| Endoscopy |
8 |
|
| Barium Studies |
Biphasic esophagram (double contrast and single contrast) |
8 |
|
Single contrast esophagram |
6 |
Probably indicated if that is all the patient can do. |
Modified barium swallow |
4 |
|
Dynamic and static imaging of pharynx |
4 |
|
| Esophageal manometry |
6 |
|
| Radionuclide esophageal transit scintigraphy |
4 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 4: Substernal dysphagia in immunocompromised
patients.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| Endoscopy |
8 |
|
| Barium Studies |
Biphasic esophagram (double contrast and single contrast) |
8 |
|
Single contrast esophagram |
5 |
|
Modified barium swallow |
4 |
|
Dynamic and static imaging of pharynx |
3 |
|
| Esophageal manometry |
2 |
|
| Radionuclide esophageal transit scintigraphy |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Dysphagia is defined as the subjective awareness of swallowing difficulty during passage of a solid or liquid bolus from the mouth to the stomach. This symptom can be caused by functional or structural abnormalities of the oral cavity, pharynx, esophagus, or even the gastric cardia. A barium study may be performed with videofluoroscopy to assess pharyngeal function and esophageal motility as well as a series of double- and single-contrast static images to assess structural abnormalities such as rings, strictures, and tumors. Other possible diagnostic tests include a modified barium swallow, endoscopy, manometry, and nuclear scintigraphy esophageal transit studies. The choice of test may depend on the clinical setting as well as the nature and location of the patient's dysphagia.
Clinical Perspective
Many patients with dysphagia can subjectively localize a sensation of blockage or discomfort to the throat or substernal region. Patients with pharyngeal dysphagia typically complain of food sticking in the throat or of a globus sensation with a lump in the throat. Other symptoms of oropharyngeal dysfunction include coughing or choking during swallowing due to laryngeal penetration or aspiration, a nasal-quality voice or nasal regurgitation due to soft palate insufficiency, and food dribbling from the mouth or difficulty chewing due to an abnormal oral phase of swallowing. When oropharyngeal
dysphagia has an attributable cause (e.g., recent stroke), a modified barium swallow may be the appropriate test to assess the patient’s swallowing status and initiate treatment by a speech therapist. In patients with unexplained oropharyngeal dysphagia, however, a more detailed barium study may be needed to determine the cause. It also is important to recognize that abnormalities of the mid or distal esophagus or even the gastric cardia may cause referred dysphagia to the upper chest or pharynx, whereas abnormalities of the pharynx rarely cause referred dysphagia to the lower chest. The esophagus and cardia should therefore be evaluated in patients with pharyngeal symptoms, particularly if no abnormalities are found in the pharynx to explain these symptoms. Thus, a combined radiologic examination of the pharynx, esophagus, and gastric cardia
is appropriate for patients with unexplained pharyngeal dysphagia.
Other patients may have substernal dysphagia with a sensation of blockage or discomfort anywhere from the thoracic inlet to the xiphoid process. This symptom may be caused by esophageal motility disorders or by structural abnormalities of the esophagus or cardia such as esophagitis, rings, strictures, and tumors. When barium studies are performed on these patients, the esophagram usually consists of a biphasic examination that includes upright double-contrast views with a high-density barium suspension to assess mucosal disease and prone single-contrast views with a low-density barium suspension to assess distensibility and motility.
Optimal evaluation of patients with dysphagia depends on the nature and location of the dysphagia and the clinical setting. The following four scenarios are considered separately:
- Oropharyngeal dysphagia with an attributable cause
- Unexplained oropharyngeal dysphagia
- Substernal dysphagia in immunocompetent patients
- Substernal dysphagia in immunocompromised patients
Oropharyngeal Dysphagia with an Attributable Cause
When oropharyngeal dysphagia has an attributable cause (e.g., recent stroke, worsening dementia, myasthenia gravis, amyotrophic lateral sclerosis), a modified barium swallow may be performed with the assistance of a speech therapist. The study is facilitated by examining the patient in a speech therapy chair. The modified barium swallow focuses on the oral cavity, pharynx, and cervical esophagus with videofluoroscopy or cine recording to assess abnormalities of both the oral phase of swallowing (e.g., difficulty propelling the bolus) and the pharyngeal phase (e.g., laryngeal penetration, cricopharyngeal dysfunction). The patient may be given high- and low-density barium suspensions as well as other substances of varying consistency (e.g., barium paste or barium-impregnated crackers) to assess the patient's ability to
swallow solid or semisolid substances. In conjunction with a speech therapist, various compensatory maneuvers (e.g., a chintuck position) may be tried to prevent aspiration or other types of swallowing dysfunction.
Unexplained Oropharyngeal Dysphagia
In patients with unexplained oropharyngeal dysphagia, a more detailed barium study may be performed in order to assess both functional and structural abnormalities of the pharynx. As in the modified barium swallow, a dynamic
examination of the pharynx with videofluoroscopy or cine recording permits assessment of both the oral and pharyngeal phases of swallowing. However, static images of the pharynx (e.g., double-contrast spot films of the pharynx in frontal and lateral projections with high-density barium) should also be obtained to detect structural abnormalities (e.g., pharyngeal tumors, Zenker’s diverticulum). Because some patients with lesions in the esophagus or at the gastric cardia can have referred dysphagia, the esophagus and cardia should also be carefully evaluated as part of the barium study in these patients (see below). In patients with unexplained pharyngeal dysphagia, it has been shown that the combination of videofluoroscopy and static images of the pharynx and esophagus has a higher diagnostic value than either videofluoroscopy
or static images alone.
Substernal Dysphagia in Immunocompetent Patients
The biphasic esophagram is a valuable technique for evaluating substernal dysphagia in immunocompetent patients. This technique permits detection of both structural and functional abnormalities of the esophagus. Perhaps the most important structural lesion is carcinoma of the esophagus or esophagogastric junction. In a study, double-contrast esophagography was found to have a sensitivity of 96% in diagnosing cancer of the esophagus or esophagogastric junction, which is comparable to the reported sensitivity of endoscopy for diagnosing these lesions. In two other large series of patients, endoscopy failed to reveal any cases of esophageal carcinoma that had been missed on the barium studies. The findings in these series suggest that endoscopy is not routinely warranted to rule out missed tumors in patients who have normal
findings on radiologic examinations.
While double-contrast views are best for detecting mucosal lesions (e.g., tumors, esophagitis), prone single-contrast views with continuous drinking of a low-density barium suspension are best for detecting lower esophageal rings or strictures. It has been shown that lower esophageal rings are two to three times more likely to be diagnosed on prone single-contrast views than on upright double-contrast views because of inadequate distention of the distal esophagus when the patient is upright. In one study, the biphasic esophagram was found to detect about 95% of all lower esophageal rings, whereas endoscopy detected only 76% of these rings. Similarly, biphasic esophagrams have been found to have a sensitivity of about 95% in detecting peptic strictures, sometimes revealing strictures that are missed with endoscopy.
Alternatively, endoscopy may be performed to evaluate the esophagus for structural abnormalities in patients with dysphagia. It is a highly accurate test for esophageal cancer when multiple endoscopic biopsy specimens and brushings are obtained. It also is more sensitive than double-contrast esophagography for detecting mild reflux esophagitis or other subtle forms of
esophagitis. However, endoscopy is a more expensive and invasive test than the barium study. It also is less sensitive than the barium study for detecting lower esophageal rings or strictures (see above) and does not permit evaluation of esophageal motility disorders. For these reasons, the barium study is often recommended, even by gastroenterologists, as the initial diagnostic test for patients with dysphagia.
The biphasic esophagram is also a useful test in patients with esophageal motility disorders causing dysphagia. Videofluoroscopy of discrete swallows of a low-density barium suspension in the prone right anterior oblique position
permits detailed assessment of esophageal motility. In various studies, videofluoroscopy has been found to have an overall sensitivity of 80% to 89% and specificity of 79% to 91% for the diagnosing of esophageal motility disorders (e.g., achalasia, diffuse esophageal spasm) in comparison to esophageal manometry. When a significant esophageal motility disorder is detected on barium study, manometry may be performed to further elucidate the nature of this motility disorder. Alternatively, radionuclide esophageal transit scintigraphy is a simple, noninvasive, and quantitative test of esophageal motility and emptying.
Substernal Dysphagia in Immunocompromised Patients
The major consideration in immunocompromised patients with dysphagia or odynophagia (painful swallowing) is infectious esophagitis, most commonly due to Candida albicans or herpes simplex virus. In HIV-positive patients, Candida is the cause of esophageal symptoms in the majority of cases, with cytomegalovirus (CMV), herpes simplex, and idiopathic ulcers (also known as HIV ulcers) the other most common etiologies. HIV-positive patients with esophageal symptoms are
generally treated empirically with antifungal therapy without undergoing a diagnostic examination. Most gastroenterologists prefer that those with persistent symptoms (or severe symptoms at presentation) be evaluated by endoscopy. Endoscopy is preferred because of the ability to obtain specimens (e.g., histology, cytology, immunostaining and culture). The endoscopic or radiographic appearance alone does not accurately predict diseases other than Candida esophagitis; diagnosis requires the acquisition of specimens for laboratory study. Barium esophagography is preferred in some centers and can be useful in guiding management. Double-contrast esophagography is more accurate than single-contrast esophagography for detecting ulcers or plaques associated with infectious esophagitis. However, single-contrast esophagrams may be performed if the patient is too sick or debilitated to tolerate a double-contrast examination. Patients with radiographically diagnosed Candida or herpes esophagitis may be treated with antifungal or antiviral agents without
endoscopic evaluation, but endoscopy is warranted for patients with giant esophageal ulcers in order to differentiate CMV and HIV, so that appropriate therapy can be started.
