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The differential diagnosis for a patient with dysphagia is quite broad. It is useful to try to distinguish between oropharyngeal dysphagia (also called "transfer dysphagia") and esophageal dysphagia (also called "transit dysphagia").
Oropharyngeal dysphagia is characterized by a difficulty in transferring the contents of the oropharynx into the upper esophagus. This difficulty is often manifested by coughing, choking, and nasal regurgitation. The food bolus has a tendency to remain in the hypopharynx. Illnesses associated with this form of dysphagia include neural disorders (eg, stroke, amyotrophic lateral sclerosis, multiple sclerosis, and various neuropathies), muscle diseases (eg, polymyositis, muscular dystrophy, myasthenia gravis, and metabolic myopathies), and mechanical obstruction (eg, Zenker's diverticulum, cervical osteophyte, and thyromegaly).
Esophageal dysphagia refers to diseases that affect the ability to propel the food bolus from one part of the esophagus to another. It is characterized by the sensation of food "sticking" or "getting hung up" in the neck or chest. The differential diagnosis includes mechanical obstruction (eg, benign strictures, webs, rings, neoplasms, diverticulum, and vascular anomalies) and motility disorders (eg, achalasia, spastic motility disorders, and scleroderma). Motility disorders frequently are associated with difficulty in swallowing both solids and liquids. Mechanical obstruction usually begins with difficulty swallowing solids and later progresses to include trouble with liquids. The patient had symptoms most consistent with mechanical esophageal dysphagia.
A confusing part of this patient's history was that after she had undergone an EGD in Mexico, her physician told her that a blood vessel might be blocking the esophagus. This report made dysphagia lusoria a possibility. Arteria lusoria is an aberrant right subclavian artery that has its origin in the descending aorta and takes a retroesophageal course to the right upper thorax. This anatomic abnormality can cause upper esophageal mechanical dysphagia. However, dysphagia lusoria is not associated with severe iron deficiency anemia, which the patient obviously has. A unifying diagnosis would be a disease associated with mechanical esophageal dysphagia that either causes, or is caused by, iron deficiency. Neoplasms can cause mechanical esophageal dysphagia, as well as gastrointestinal blood loss. However, a 6-year history seems too long for an ulcerated neoplasm of the esophagus. A benign peptic stricture could be associated with gastrointestinal blood loss from ulcerated esophageal mucosa. One could even hypothesize a scleroderma-like motility disorder and stricture that is associated with the rheumatoid arthritis. Theoretically, severe gastroesophageal reflux disease could explain both the dysphagia and the anemia. However, this patient has no history of heartburn, and the location of the obstruction (according to patient history) appears to be high in the esophagus.
Severe iron deficiency can cause mechanical esophageal dysphagia. An upper esophageal web, in association with iron deficiency anemia (Plummer-Vinson syndrome), is a possible explanation of the patient's problem, but another source of gastrointestinal blood loss would have to be hypothesized.