Case 1: Diagnosing difficult deglutition

Abstract

A 16-year-old girl with a long-standing history of dysphagia was referred to the gastroenterology service by her family paediatrician. The difficulty in swallowing had been present intermittently since early childhood and had recently become more prominent, making her seek medical attention. The patient had noticed difficulty swallowing certain types of solid foods, notably meat and bread. She had a feeling of food getting stuck in the throat and of discomfort in that area. On a few occasions, she had vomited undigested food. There was no problem swallowing liquids. There was no odynophagia, heartburn, regurgitation, drooling, abdominal pain, chronic cough, headaches or weight loss. She never presented with a bolus obstruction. Her symptoms were nonprogressive. A system inquiry was negative. She was a well-adjusted adolescent, performing very well in school and being active in sports and extracurricular activities. Her history was unremarkable with normal growth and development. A family history for dysphagia was negative. A physical examination had revealed a healthy looking girl. Her weight was between the 75th and 90th percentile, and her height was above the 97th percentile. Her physical examination was completely normal. A variety of proton pump inhibitors at adequate doses were tried without any response. A barium study had revealed no abnormality in the swallowing mechanism. The esophagus was unremarkable. The patient was referred to the surgical service of her regional hospital, and an upper gastrointestinal endoscopy was performed. The esophagus was reported to be completely normal. Mild, nonspecific erythema was noted in the gastric antrum. However, biopsies taken from the antrum did not reveal any Helicobacter pylori infection. An assessment by an otolaryngologist had revealed a normal larynx and hypopharynx with good vocal cord mobility and no mass effect. Given all the negative investigations, the impression was that the patient may have psychogenic dysphagia. When seen at the gastroenterology clinic, the patient’s symptoms were unchanged and her physical examination was normal. A diagnostic test was performed. The term dysphagia is derived from the Greek roots “dys” (with difficulty) and “phagia” (to eat). It is defined as the subjective sensation of having difficulty swallowing and can occur from any process that produces difficulty with active transport of food and liquid from mouth to stomach. In the paediatric population, dysphagia is an uncommon but an alarming symptom. The differential diagnosis of dysphagia in children is wide, including congenital, infectious, inflammatory, systemic, traumatic and neoplastic causes. Dysphagia can be broadly classified into two types, based on its origin: pharyngeal or esophageal. The causes of pharyngeal dysphagia are mainly neuromuscular in nature, causing difficulty in swallowing both liquids and solids – patients typically experience more difficulty swallowing liquids. Esophageal dysphagia may be due to problems in the lumen (tumours, stricture, web, ring, foreign body, etc), wall (esophagitis, connective tissue disorders, achalasia, etc) or extramural (mediastinal mass). This type of dysphagia typically leads to difficulty swallowing solid foods. Occasionally, no etiology is found for dysphagia. Most causes of dysphagia are apparent on the history and physical examination of the patient. A barium swallow is the investigation of choice in dysphagia and would help to exclude anatomical problems.