Signs and symptoms: Dysphagia is a subjective sensation caused by the obstruction of the propulsion of food from the throat to the stomach. When asked, “When you swallowed your pasta, bread, or apple, did you feel that the food was obstructed in your chest?” The patient may point to an obstruction at the suprasternal notch, when in fact the food has already passed to the gastroesophageal junction. The obstruction may be relieved by drinking water, lifting the upper extremity over the head, or changing position. Some patients complain of pain or excessive salivation without the sensation of obstruction. Patients are often unaware of the symptoms and only notice them when asked. Some patients also have difficulty swallowing liquid food and often experience nasal reflux, which may be related to esophageal motility disorders. In other patients, dysphagia occurs in the non-esophageal phase of swallowing and is called oropharyngeal dysphagia, usually with complaints of obstruction above the suprasternal notch and often accompanied by aspiration, coughing or salivation. In patients with dysphagia, physical examination is usually not positive, but evidence of neurological disease can be found in oropharyngeal dysphagia. Painful swallowing is less common than dysphagia, and acute painful swallowing often suggests infection (fungal, herpes, cytomegalovirus) or pharmacologic esophagitis. Some patients may have an accompanying oropharyngeal herpes virus infection or thrush. Differential diagnosis: The common causes of dysphagia are listed in Table 1-2. GERD and stricture due to benign esophageal rings (Schatzki rings) are the most common causes of dysphagia. Patients with dysphagia without esophageal strictures caused by GERD tend to have milder symptoms and are not associated with prolonged food impaction. Esophageal cancer is often associated with weight loss. Zenker’s diverticulum presents as a neck mass or coughing up the remains of food eaten several hours ago. People with congenital esophageal strictures are slow eaters from birth. Difficulty swallowing liquids is often indicative of cardia incontinentia, diffuse esophageal spasm and associated spastic functional abnormalities. Oropharyngeal dysphagia is often caused by neuromuscular lesions or other lesions unrelated to the gastrointestinal tract. Drug esophagitis is a common cause of painful swallowing. Common medications include doxycycline, quinidine, alendronate, potassium tablets, aspirin, and other NSAIDs. Esophagitis due to Candida, herpesvirus, and cytomegalovirus infections often presents with significant painful swallowing. patients with HIV may have esophageal ulcers of unknown origin. Table 1-2 Etiology of dysphagia and painful swallowing Dysphagia Painful swallowing Esophageal strictures and esophageal rings Drug esophagitis GERD without esophageal strictures Herpesvirus esophagitis Esophageal cancer Candida esophagitis External pressure lesions Cytomegalovirus esophagitis Benign esophageal tumors Unexplained esophageal ulcers Zenker’s diverticulum Other esophageal diverticula Eosinophilic esophagitis Congenital esophageal strictures Delayed cardia Diffuse esophageal spasm Other spastic diseases Oropharyngeal lesions Methods of diagnosis and treatment: EGD should be performed for intermittent solid food swallowing difficulties to clarify the diagnosis, and if necessary, esophageal dilatation therapy is feasible. For those with severe symptoms and high suspicion of Zenker’s diverticulum, other proximal esophageal lesions or cardia incontinence, barium meal examination should be performed. Patients with Zenker’s diverticulum are at greater risk of perforation when EGD is performed. If EGD is not available, a barium swallow of 13 mm can help to clarify the site of esophageal stricture and exclude esophageal masses. However, barium imaging is less sensitive to esophagitis and is not therapeutic. In patients with symptoms suggestive of power abnormalities, esophageal manometry is required to clarify the diagnosis after organic pathology has been excluded. Before completing the examination, the patient should be advised to eat carefully to prevent food impaction. If the patient has significant GERD symptoms, PPI treatment may be attempted while waiting for the examination.