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doi:10.1111/j.1440-1746.2012.07097.x

A D VA N C E S I N C L I N I C A L P R A C T I C E jgh_7097 873..881

Current and future techniques in the evaluation

of dysphagia
Paul Kuo, Richard H Holloway and Nam Q Nguyen
Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia

Key words Abstract

dysphagia technique, endoscopy: upper
gastrointestinal, esophageal motility,
esophagus.
Accepted for publication 23 January 2012.
Correspondence
Dr Nam Nguyen, Department of
Gastroenterology and Hepatology, Royal
Adelaide Hospital, North Terrace, Adelaide,
SA 5000, Australia. Email:
quoc.nguyen@health.sa.gov.au
Dysphagia is common in the general population, and is generally due to either mechanical
obstruction or dysmotility. Patient demographics and symptom evaluation are often useful
in determining the likely cause, and guide subsequent investigation and management.
Oropharyngeal dysphagia is usually caused by neurological conditions where treatment
options are limited. Conversely, many of the esophageal causes of dysphagia are amenable
to therapy. Gastroscopy is often the first test of choice, given its diagnostic and therapeutic
potential, especially when mechanical causes are concerned. Esophageal motor function
can be assessed by a variety of techniques, ranging from radiology such as barium swallow,
to dedicated motility tests such as manometry and impedance monitoring. The choice of
test relies on the clinical indication and the results should be interpreted in conjunction with
the patients symptoms. High-resolution manometry with topography is now the new
benchmark for motility studies. Several new techniques for motility testing have also
become available, such as esophageal ultrasound and functional lumen imaging probe, but
are currently limited to the research setting.

the feeling of food/drink sticking, or a discomfort either in the

Introduction
Dysphagia, or difficulty in swallowing, affects up to 22% of
patients in the primary care setting,1 and represents one of the most
common reasons for referral to gastroenterologists. While the
history is the most important part of clinical assessment, bedside
assessment alone is often inadequate in achieving a diagnosis.
Further testing is therefore usually required and may include
barium swallow, upper gastrointestinal endoscopy and, where
available, esophageal manometry. More recently, several new tests
have become available for esophageal motility assessment,
although their utility in the clinical setting remains to be estab-
lished. Nevertheless, these new techniques offer the opportunity to
provide further insights into various motility disorders, thus to
improve our understanding of these diseases and, hopefully, lead
to identification of new therapeutic targets. This paper aims not
only to review the current clinical and laboratory assessments of
dysphagia but also the emerging techniques that have been devel-
oped recently that allow better understanding of esophageal motor
function.
Clinical assessment
Dysphagia is a very non-descriptive term that can result from any
problem arising between the posterior oral cavity and the proximal
stomach. The term also gives no clue as to whether the problem is
primarily a motor or sensory one. Typically, patients complain of
throat or retrosternally, or simply being able to sense the act of
swallowing; occasionally, regurgitation, aspiration, or even hiccup
may be the presenting complaint.2
The most important first step in assessing dysphagia is to deter-
mine whether it is oropharyngeal or esophageal in origin, as their
potential causes and subsequent investigation and management
can differ greatly. This can usually be achieved through taking a
careful history, which has been shown to accurately differentiate
between oropharyngeal, esophageal, and neuromuscular causes of
dysphagia in up to 85% of patients.3 It is important to know if the
dysphagia is present only during swallowing or at all times, the
latter suggests potential sensory dysfunction, and the most
common disorder is globus hystericus. Dysphagia that occurs only
during swallowing of solids is more likely to indicate underlying
mechanical obstruction, whereas when both solids and liquids are
affected, dysmotility is the likely cause. The presence of symp-
toms such as delayed or absent swallow initiation, cough post-
swallowing, nasopharyngeal regurgitation, and repeated swallows
to effect pharyngeal clearance, indicate potential oropharyngeal
dysphagia.2
Localization of the hold-up site based on symptom is not always
a reliable guide to the site of the obstruction.2,4 However, dysph-
agia felt in the throat is more likely to be oropharyngeal in origin
as compared with that in the retrosternal region, which is more
suggestive of an esophageal disorder. The duration and progres-
sion of symptoms are also important features. Chronic and stable

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Evaluation of dysphagia P Kuo et al.

symptoms suggest benign conditions such as peptic strictures or Table 1 Causes of oropharyngeal dysphagia. (adapted from Cook IJ,
Schatzkis ring, while rapidly progressive symptoms, especially in 20092)
association with weight loss, indicate a more sinister cause. The
Central nervous system Drugs
presence of regurgitation immediately after swallowing suggests Stoke Centrally acting
esophageal retention of food, whereas regurgitation in between Extrapyramidal syndromes Phenothiazines
meals indicates the presence of a pharyngeal pouch or Zenkers (Parkinson, Huntington, Metoclopramide
diverticulum. Wilsons) Benzodiazepines
Dysphagia that occurs after a long history of reflux symptoms, Brainstem tumors Antihistamines
especially with patients giving a history of poor symptom control, Alzheimers Drugs acting at neuromuscular
may suggest the development of complications such as peptic Motor neurone disease junction
stricture, Barretts esophagus and possibly, esophageal adenocar- Peripheral nervous system Botulinum toxin
cinoma. Patients with known esophageal dysmotility often have Spinal muscular atrophy Procainamide
volume reflux, and throat irritation caused by reflux can induce the Guillain-Barre Penicillamine
sensation of dysphagia. In young patients who present with dys- Post-polio syndrome Erythromycin
phagia or food bolus obstruction, especially those with a history of Myogenic Aminoglycosides
atopy, eosinophilic esophagitis must be suspected and esophageal Myasthenia gravis Drugs toxic to muscle
biopsies must be performed on subsequent gastroscopy. Polymyositis/dermatomyositis, Amiodarone
Dysphagia may be a complication of systemic disease or medi- inclusion body myositis Alcohol
cation. Oropharygenal dysphagia is common in patients with a Thyrotoxicosis HMG-CoA reductase inhibitors
Paraneoplastic syndrome Cyclosporin
history of head and neck surgery or radiotherapy, stroke and other
Structural disorders Penicillamine
neurological conditions such as Parkinsons disease and motor
Zenkers diverticulum Miscillaneous, presumed
neuron disease. A detailed neurological examination would, there-
Cricopharyngeal bar or stenosis neuromyopathic
fore, be an important part of the clinical evaluation of orophagy-
Cervical (mucosal) web Digoxin
ngeal dysphagia. It is equally important to look for peripheral skin
Oropharyngeal tumor Trichloroethylene
and joint stigmata of scleroderma, CREST syndrome or systemic Head and neck surgery Vincristine
connective tissue disease, as these patients are at risk of esoph- Radiotherapy Drugs inhibiting salivation
ageal hypomotility. Medications such as dopamine antagonists and Anticholinergics
anti-cholinergic agonists can lead to xerostomia and esophageal Antidepressants
dysmotility. The presence of xerostomia should be enquired, as Antipsychotics
treatment is simple and effective. In elderly patients, pill-induced Antiparkisonian drugs
ulceration and stricture should be suspected for those who take Antihypertensives
bisphosphonates and non-steroidal anti-inflammatory drugs. Diuretics
Finally, risk factors for esophageal and gastric cancers such as
smoking, alcohol use, ethnic background and known family
history of upper gastrointestinal (GI) malignancy should be noted.
lower esophageal sphincter, leading to anatomical obstruction.
Tumors in the region of the lower esophageal sphincter or gastric
Oropharyngeal dysphagia cardia can give rise to pseudo-achalasia with identical clinical
It is important to remember that although healthy aging is related presentation. Eosinophilic esophagitis has recently been recog-
to certain neuromuscular changes, it rarely leads to clinically sig- nized as an increasing common cause of dysphagia and food bolus
nificant dysphagia.2 Therefore, the presence of oropharyngeal dys- impaction. Histologically, eosinophilic esophagitis is character-
phagia will always require a search for an underlying cause ized by marked eosinophilic infiltration and associated inflamma-
(Table 1). The biggest clue to the cause of a patients oropharyn- tion in the esophagus and, in patients with longstanding disease,
geal dysphagia lies with age. Development of oropharyngeal dys- marked fibrosis of the esophageal wall. This, in turn, can lead to
phagia in an elderly person (age > 70 years) may relate to either an significant stiffening, luminal narrowing, and impaired peristal-
acute neurological event such as a stroke, or a progressive neuro- sis of the esophagus. The diagnosis of this condition heavily
logical disease such as Parkinsons disease and Alzheimers. relies on clinical awareness, endoscopic features and esophageal
Zenkers diverticulum is also more prevalent in the elderly. In biopsies.
contrast, degenerative motor neuron diseases must be suspected in
younger patients.
General approach to investigation
Accurate identification of the cause of dysphagia usually requires
Esophageal dysphagia
investigations that can be broadly divided into imaging and motil-
The causes of esophageal dysphagia can be broadly divided into ity assessment. The main aims are to exclude a potentially fatal
either mechanical or dysmotility (Table 2). There are, however, a pathology such as cancer, and to identify a potentially treatable
number of conditions in which dysphagia is mediated by both cause. The choice of test(s) depends largely upon the perceived
mechanical and dysmotility mechanisms. Achalasia is a classic underlying cause, as the sensitivity and specificity of each test
example of such a condition, where there is often a failure of differs depending on the underlying condition, in large part
peristalsis in the esophageal body with impaired relaxation of the because of the inherent capability of the technique. Given the

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P Kuo et al. Evaluation of dysphagia

Table 2 Causes of esophageal dysphagia: mechanical versus over recent decades, having progressed from single-channel
dysmotility manometry to the modern day 36-channel high-resolution manom-
etry with topography,5 impedance monitoring,6,7 planimetry,8,9 and
Mechanical Dysmotility
intraluminal ultrasound.10 However, each of these techniques is
Benign strictures Achalasia only designed to measure one out of three important aspects of
Peptic stricture Diffuse esophageal spasm esophageal motor function assessment namely, muscular contrac-
Schatzkis ring Eosinophilic esophagitis tile activity, intraluminal pressure, and bolus transit. To overcome
Webs Reflux esophagitis and this, a combined approach incorporating more than one technique
Post-surgical or anastomosis Barretts esophagus is being increasing adopted.
Caustic injury
Radiation injury
Eosinophilic esophagitis Current techniques for assessing
Extrinsic compression (e.g. benign dysphagia
inflammatory mediastinal lymph
node, spine osteophyte, vascular Barium swallow
compression)
External compression e.g. large The barium swallow remains a widely available and relatively
Zenkers diverticulum, cardiac inexpensive first-line investigation for dysphagia. It remains
or pulmonary mass attractive in those who are either poorly tolerant of, or unfit to
Post fundoplication undergo, other procedures, such as gastroscopy. Fluoroscopy
Malignant strictures offers real-time and continuous viewing of the bolus during transit
Squamous cell carcinoma from the oropharynx into the stomach, and transit of both liquid
Adenocarcinoma and solid boluses should be evaluated. It is non-invasive and pro-
Extrinsic compression (e.g. vides a good qualitative and potentially quantitative functional
malignant mediastinal lymph node, assessment of the esophagus, including the upper and lower esoph-
lung cancer, lymphoma) ageal sphincters. Barium swallow may also demonstrate any
obvious anatomical abnormality including stricture, Schatzkis
ring, and mass lesion. Additional advantages include its wide
availability compared with other more specialized techniques, and
differences in the causes as well as the anatomical structures lower cost. It is therefore a useful first investigation for dysphagia.
responsible for oropharyngeal and esophageal dysphagia, the However, barium swallow is operator and interpreter dependent.
approaches for their investigation are different. While it has poor sensitivity for subtle abnormalities and entails
exposure to ionizing radiation, it is more sensitive in detecting
Oropharyngeal dysphagia esophageal webs and rings than gastroscopy.
It has been proposed that a timed barium swallow (TBE) is
Available diagnostic tests include standard barium swallow, useful for assessing the response to treatment of achalasia. Fol-
modified barium swallow, nasoendoscopy, and pharyngeal lowing either myotomy or pneumatic dilatation, the height of
manometry. Modified barium swallow is carried out by both a the barium column at 1 min post-contrast ingestion 6 months
radiologist and speech pathologist. It offers real-time assessment after treatment was found to correlate with symptom scores.
and recording of oropharyngeal coordination and the presence Conversely, a lack of TBE improvement predicted treatment
and extent of aspiration, and allows instant feedback on the effect failure.11
of swallowing maneuvers and posture. Nasoendoscopy, also
known as fiber optic endoscopic examination of swallowing, not
only allows direct visualization of lingual, pharyngeal, and epig- Upper endoscopy
lottic movements during swallowing but also assesses the pres- Upper GI endoscopy, often known as gastroscopy, not only pro-
ence of any pharyngeal retention of liquids or solids after vides direct visualization of the esophagus but also the oro-
swallowing. Pharyngeal manometry is particularly useful in pharynx, stomach and duodenum. For many patients, especially
detecting failure of upper esophageal sphincter relaxation, the those with a history that is suggestive of a mechanical obstruction,
presence of which indicates potential therapeutic benefit with cri- gastroscopy is the preferred first-line investigation. It is particu-
copharyngeal myotomy or dilatation, although evidence for this is larly useful in identifying intraluminal mass lesions, strictures and
largely anecdotal. inflammatory disorders such as reflux disease, eosinophilic esoph-
agitis, and pill-induced ulceration.
In addition to the ability to take mucosal biopsies to confirm a
Esophageal dysphagia
histological diagnosis, the major advantage of gastroscopy is its
Mechanical causes, such as an obstructing mass lesion or stricture, therapeutic potential. Although eosinophilic esophagitis classi-
are predominantly identified during gastroscopy, while motility cally presents as linear furrows, circular rings, ulceration or stric-
disorders such as achalasia and spasm are diagnosed by manom- turing of the esophagus on gastroscopy (Fig. 1), a significant
etry. However, a video barium swallow remains a useful investi- proportion of patients have normal appearing esophagus. Thus,
gation and, in some situations, outperforms gastroscopy. routine mucosal biopsying is recommended in all patients with
Assessment of esophageal motility has advanced substantially dysphagia without an obvious identifiable cause, even if the

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2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Evaluation of dysphagia
esophagus appears entirely normal. Esophageal dilatation is
an effective therapeutic modality for esophageal web, peptic stric-
ture, anastomotic stricture, radiation related stricture or Schatzkis
ring. For patients with achalasia who are not suitable for
surgical myotomy, endoscopic-guided pneumatic dilatation and
botulinum toxin injection at the LOS are the other therapeutic
alternatives.
Gastroscopy can also be useful in providing clues to an under-
lying motility disorder. While the sensitivity and specificity are
relatively low, the presence of a dilated esophagus, a paucity of
lumen-occluding contractions, and a tight lower esophageal
sphincter could suggest potential underlying achalasia. Gastros-
copy should also be considered as part of the assessment of acha-
lasia by direct visualization of the gastro-esophageal junction and
gastric cardia in order to detect any underlying carcinoma causing
pseudoachalasia.12 On rare occasions, the only clue for
pseudoachalasia related to malignancy outside the GI tract is a lack
of ability to completely efface the waist of the lower esophageal
sphincter narrowing on pneumatic dilatation (Fig. 2).
Manometry
Manometry is the most sensitive and accurate technique to diag-
nose esophageal motility disorders.5,13 While the technique has
been available for over 30 years, recent advances in technology
have substantially improved its recording power and fidelity. Stan-
dard manometry relies on a perfused assembly with 8 or 16 record-
ing points. However, high-resolution manometry (HRM) has been
developed with up to 36 recording points. This enables pressure
measurements of 1 cm or less apart along the entire esophagus,
876
2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
P Kuo et al.
Figure 1 Endoscopic appearance of eosino-
philic esophagitis: (a) furrow (b) rings (c)
luminal narrowing and structuring (arrows),
and (d) a linear ulcerative tear after a food
bolus obstruction.
thus providing more detailed mapping of esophageal motor func-
tion, including the upper and lower esophageal sphincters.5,1315
A further advancement in manometry has been the invention of
the topographical (or contour, or color) plot, which has largely
replaced the traditional line plot (Fig. 3).16,17 The main advantage
is more rapid interpretation of results, as it is easier for the human
eye to recognize colors rather than lines. The combination of HRM
with topography, termed high-resolution esophageal pressure
topography,18 allows more precise measurement of esophageal
pressures, and has been shown to have superior diagnostic sensi-
tivity for achalasia compared with limited conventional manom-
etry (72% vs 56%).17 However, despite the improved sensitivity
of HRM compared with conventional manometry, convincing
additional benefit in terms of patient outcome remains to be
demonstrated.
Overall, manometry, whether it be in the conventional or high-
resolution form, remains the most important tool in assessing
esophageal motility. It is highly sensitive in detecting pressure
changes, correlates reasonably well with bolus transit, and remains
the gold-standard test in diagnosing conditions such as achalasia
and esophageal spasm.
Scintigraphy
Scintigraphy is an often forgotten and somewhat superseded test
for assessing dysphagia. The main role for the radionuclide transit
test is as a screening test to detect an esophageal transit problem.
It involves the ingestion of a liquid or solid bolus labeled with a
radionuclide such as 99mTc-DTPA, and the radionuclide movement
recorded by a gamma camera, capable of measuring esophageal
Journal of Gastroenterology and Hepatology 27 (2012) 873881
P Kuo et al.
Figure 2 A case of progressive dysphagia
due to pseudoachalasia related to lung cancer.
Upper gastrointestinal (GI) endoscope
showed a normal gastro-esophageal junction
(GOJ) with no mucosa lesion (a,b). Barium
swallow outlined a narrowing at the gastro-
esophageal junction (GOJ) (c), in which the
waist of the narrowing at the failed to efface
by a 35 mm pneumatic balloon dilator main-
tained at 18 psi pressure (d, white arrow).
Despite the normal appearing high resolution
computed tomography (CT) scan, endoscopic
ultrasound showed an eccentric wall thicken-
ing and an adjacent mass at the GOJ; EUS
guided fine needle aspiration obtained large
cell carcinoma of lung origin (e).
bolus transit time and clearance.1922 Even though it is reported to
have high sensitivity and specificity in detecting esophageal motor
abnormalities,20 scintigraphy has a number of disadvantages,
including handling of radioactive material and radiation exposure,
poor anatomical definition compared with barium swallow, and a
lack of well-defined diagnostic criteria. Hence, this technique is
rarely used in clinical practice.
Future and emerging techniques for
esophageal motility assessment
Multichannel intraluminal impedance
Until recently, the only method to measure bolus transit in the
esophagus was by fluoroscopy or scintigraphy. However, these
are unsuitable for routine and repeated use due to exposure to
ionizing radiation. Impedance monitoring in the esophagus offers
an alternative method to assess bolus transit without exposure to
radiation. It has been shown to have an accuracy of 97% com-
pared with fluoroscopy.23 Impedance uses the changes in electri-
cal conductivity associated with the passage of a bolus to map
bolus transit and clearance (Fig. 4). Recent developments have
enabled the data to be depicted as a topographical plot as with
manometric data.
Impedance monitoring is used in combination with manometry
in the evaluation of non-obstructive dysphagia (NOD). The value
of impedance lies with it being a complementary, rather than
competing, tool to manometry by providing information on the
functional outcome of motility; namely flow or transit. Thus,
impedance allows for inferences to be made about the relationship
between abnormalities of motility seen on manometry with abnor-
malities in bolus transit seen on impedance. The use of viscous
Journal of Gastroenterology and Hepatology 27 (2012) 873881
2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Evaluation of dysphagia
boluses also provides a more physiological assessment of motility
than the more conventional liquid boluses used in manometry. In
a multi-centre study on 40 patients with NOD, impedance moni-
toring was shown to identify abnormalities of transit in 35% of
patients with NOD who had apparently normal manometric
assessment.24 Conversely, manometric abnormalities do not
always translate to abnormal bolus transit.24,25 Bolus transit was
normal in up to 15% of patients with manometric diagnosis of
ineffective esophageal motility and one third of patients with
diffuse esophageal spasm.24 Impedance, however, is of limited
use in patients with achalasia, presumably due to esophageal
retention.26
More recently, combined impedance-manometry has also been
used to assess oropharyngeal transit and risk of aspiration,27
either as an alternative or adjunct to radiology. Using fluoroscopy
as the gold standard, a number of important pressure-flow vari-
ables were identified from the combined impedance-manometry
assessment which, in turn, was used in an automated analytic
program to evaluate the swallow risk index. This approach has
been shown to positively predict pharyngeal dysfunction and risk
of aspiration.27
Functional lumen imaging probe
The functional lumen imaging probe is a largely experimental tool
not yet in routine clinical use. The technique uses impedance
planimetry, which measures impedance inside a saline-filled cylin-
drical balloon, thus allowing calculation of the cross-sectional area
of the balloon.8,28,29 This tool has been used to evaluate the opening
and pressure across the gastroesophageal junction, and may prove
to be useful in assessing patients with achalasia before and after
treatment.8
877
Evaluation of dysphagia P Kuo et al.

Figure 3 High resolution manometry with topographical analysis. Picture shows two 5 mL water swallows with the upper high pressure zone
representing the upper esophageal sphincter, and the lower high pressure zone the lower esophageal sphincter, and esophageal peristalsis in
between. The amplitude of pressure waves detected is converted to colors according to the colour code shown on the left hand side.

More recently, impedance planimetry has been further modified
to measure the axial (or longitudinal) force in the esophagus,
rather than the cross-sectional area, which offers additional infor-
mation regarding the longitudinal propulsive force exerted on a
bolus, in addition to horizontal force measured by manometry.30,31
At present, the clinical use of impedance planimetry is yet to
be established, with the most promising use being for evaluating
gastroesophageal junction compliance after treatment for
achalasia.
High frequency intraluminal ultrasound
Catheter-based high frequency intraluminal ultrasound probes
range from 13 mm in diameter, and the transducer can provide
either linear or cross-sectional images.3235 The ultrasound is able
to dynamically assess esophageal longitudinal muscle contrac-
tions, as indicated by an increase in cross-sectional muscle layer
thickness.10,35,36 When used in combination with manometry,
information on the contractions of both longitudinal and circular
muscles can be obtained.37,38
Using high frequency intraluminal ultrasound (HFIUS) in
patients with spastic esophageal disorders including achalasia,
diffuse esophageal spasm, and nutcracker esophagus, the baseline
esophageal muscle thickness was found to be greater than in
healthy volunteers.37 Further, this increase in muscle thickness
appeared to correlate with the severity of the underlying disease,
i.e. greatest in achalasia and least in nutcracker esophagus.36 In
achalasia, swallow-induced longitudinal muscle contraction was
found to be a significant contributor to esophageal emptying by
increasing pan-esophageal pressure to overcome the poorly relax-
ing lower esophageal sphincter.39 HFIUS appears to be a promis-
ing technique in measuring esophageal longitudinal muscle
contraction, with its role lying predominantly in physiological
studies, especially when used in combination with other tech-
niques such as manometry. Operator dependency, and the lack of
an automated analysis means its widespread use will be limited.

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P Kuo et al.
A recommended approach
The first step in the evaluation of dysphagia is to take a careful
history, with the aim of distinguishing whether the cause is
oropharyngeal or esophageal, and whether it is mechanical or
dysmotility. If the cause is deemed likely oropharyngeal, then
referral to a neurologist or ENT specialist, with or without speech
pathologist involvement, will be appropriate. Unless an esoph-
ageal cause can be confidently excluded based on history, then
Figure 4 Impedance tracing for measuring bolus transit, outlining the
corresponded changes in pressure and impedance traces at different
bolus position in relation to the recording segment.
Figure 5 A recommended algorithm for the
evaluation of dysphagia. DES, diffuse esoph-
ageal spasm; HR manometry, high resolution
manometry.
Journal of Gastroenterology and Hepatology 27 (2012) 873881
2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Evaluation of dysphagia
further esophageal assessment must take place, with at least a
gastroscopy (provided the patient is fit for such procedure), to
exclude important causes such as cancer and stricture, as well as
eosinophilic esophagitis; the only exception is when the dysphagia
occurs in the context of suspected uncomplicated reflux disease,
where an initial trial of acid suppressing therapy would be recom-
mended. The threshold to take biopsies from an apparently normal
esophagus should be low.
If the patient still suffers from troublesome symptoms despite a
normal gastroscopy (and biopsy), dedicated motility testing is
warranted. The choice of test depends largely upon the perceived
likely diagnosis, patient characteristics and local expertise. An
elderly patient with significant co-morbidities should first undergo
a barium swallow, as it is non-invasive, and the chance of finding
a treatable dysmotility condition is small; further motility testing
should not be performed and symptoms managed conservatively
unless achalasia or esophageal spasm is suspected, in which case
manometry is required to confirm the diagnosis. In a younger
patient, where the probability of a potentially treatable dysmotility
condition is high, manometry should be performed first after gas-
troscopy, ideally with high-resolution manometry with topogra-
phy, given its superior diagnostic sensitivity for achalasia,
compared with conventional manometry. If manometric findings
are unremarkable, then the patient is highly unlikely to have sig-
nificant underlying dysmotility, and subsequent management
should therefore be conservative. (Fig. 5)
Conclusion
Dysphagia is a common problem and evaluation should start with
careful history taking, to guide subsequent diagnostic testing and
management. Gastroscopy is usually the investigation of first
choice to exclude an obstructive lesion. Many techniques are cur-
rently available for assessing esophageal motor function, although
879
Evaluation of dysphagia
manometry and barium swallow remain the most clinically useful.
High-resolution manometry with topography is now the new
benchmark in assessing esophageal pressures and diagnosing con-
ditions such as achalasia and esophageal spasm. Combining
impedance with manometry in assessing bolus transit currently
remains a research tool, as is the functional lumen imaging probe
and high frequency intraluminal ultrasound.
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