This is the current release of the guideline.

This guideline updates a previous version: Levine MS, Bree RL, Rosen MP, Foley WD, Gay SB, Grant TH, Heiken JP, Huprich JE, Lalani T, Miller FH, Ros PR, Sudakoff GS, Greene FL, Rockey DC, Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® dysphagia. [online publication]. Reston (VA): American College of Radiology (ACR); 2007. 6 p. [35 references]

The appropriateness criteria are reviewed biennially and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Oropharyngeal dysphagia

To evaluate the appropriateness of initial radiologic examinations for patients with dysphagia

Patients with dysphagia

Utility of radiologic examinations in differential diagnosis

Literature Search Procedure

The Medline literature search is based on keywords provided by the topic author. The two general classes of keywords are those related to the condition (e.g., ankle pain, fever) and those that describe the diagnostic or therapeutic intervention of interest (e.g., mammography, MRI).

The search terms and parameters are manipulated to produce the most relevant, current evidence to address the American College of Radiology Appropriateness Criteria (ACR AC) topic being reviewed or developed. Combining the clinical conditions and diagnostic modalities or therapeutic procedures narrows the search to be relevant to the topic. Exploding the term "diagnostic imaging" captures relevant results for diagnostic topics.

The following criteria/limits are used in the searches:

1. Articles that have abstracts available and are concerned with humans
2. Restrict the search to the year prior to the last topic update or in some cases the author of the topic may specify which year range to use in the search. For new topics, the year range is restricted to the last 5 years unless the topic author provides other instructions.
3. May restrict the search to Adults only or Pediatrics only.
4. Articles consisting of only summaries or case reports are often excluded from final results.

The search strategy may be revised to improve the output as needed.

The total number of source documents identified as the result of the literature search is not known.

Strength of Evidence Key

Category 1 - The conclusions of the study are valid and strongly supported by study design, analysis and results.

Category 2 - The conclusions of the study are likely valid, but study design does not permit certainty.

Category 3 - The conclusions of the study may be valid but the evidence supporting the conclusions is inconclusive or equivocal.

Category 4 - The conclusions of the study may not be valid because the evidence may not be reliable given the study design or analysis.

The topic author drafts or revises the narrative text summarizing the evidence found in the literature. American College of Radiology (ACR) staff draft an evidence table based on the analysis of the selected literature. These tables rate the strength of the evidence for all articles included in the narrative text.

The expert panel reviews the narrative text, evidence table, and the supporting literature for each of the topic-variant combinations and assigns an appropriateness rating for each procedure listed in the table. Each individual panel member forms his/her own opinion based on his/her interpretation of the available evidence.

More information about the evidence table development process can be found in the American College of Radiology (ACR) Appropriateness Criteria® Evidence Table Development document (see "Availability of Companion Documents" field).

Modified Delphi Technique

When the data available from existing scientific studies are insufficient, the American College of Radiology Appropriateness Criteria (ACR AC) employs systematic consensus techniques to determine appropriateness. The ACR AC panels use a modified Delphi technique to determine the rating for a specific procedure. A series of surveys are conducted to elicit each individual panelist’s expert opinion of the appropriateness of an imaging or therapeutic procedure for a specific clinical scenario based on the available data. ACR staff distributes surveys to the panelists along with the evidence table and narrative. Each panelist interprets the available evidence and rates each procedure. Voting surveys are completed by panelists without consulting other panelists. The ratings are integers on a scale between 1 and 9, where 1 means the panel member feels the procedure is "least appropriate" and 9 means the panel member feels the procedure is "most appropriate". Each panel member has one vote per round to assign a rating. The surveys are collected and de-identified and the results are tabulated and redistributed after each round. A maximum of three rounds are conducted. The modified Delphi technique enables each panelist to express individual interpretations of the evidence and his or her expert opinion without excessive bias from fellow panelists in a simple, standardized and economical process.

Consensus among the panel members must be achieved to determine the final rating for each procedure. If eighty percent (80%) of the panel members agree on a single rating or one of two consecutive ratings, the final rating is determined by the rating that is closest to the median of all the ratings. Up to three voting rounds are conducted to achieve consensus.

If consensus is not reached through the modified Delphi technique, the panel is convened by conference call. The strengths and weaknesses of each imaging examination or procedure are discussed and a final rating is proposed. If the panelists on the call agree, the rating is accepted as the panel's consensus. The document is circulated to all the panelists to make the final determination. If consensus cannot be reached, "No consensus" appears in the rating column and the reasons for this decision are added to the comment sections.

Not applicable

Guideline developers reviewed published cost-analyses.

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.

ACR Appropriateness Criteria®

Clinical Condition: Dysphagia

Variant 1: Oropharyngeal dysphagia with an attributable cause.

Radiologic Procedure	Rating	Comments	RRL*
X-ray barium swallow modified	8
X-ray pharynx dynamic and static imaging	6
X-ray biphasic esophagram	4	Double contrast and single contrast.
X-ray barium swallow	4
Technetium (Tc)-99m transit scintigraphy esophagus	2
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Variant 2: Unexplained oropharyngeal dysphagia.

Radiologic Procedure	Rating	Comments	RRL*
X-ray pharynx dynamic and static imaging	8	Both pharyngeal and esophageal examinations needed, since patient may have referred dysphagia.
X-ray biphasic esophagram	8	Both pharyngeal and esophageal examinations needed, since patient may have referred dysphagia. Double contrast and single contrast.
X-ray barium swallow modified	6
X-ray barium swallow	6
Technetium (Tc)-99m transit scintigraphy esophagus	4
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Variant 3: Retrosternal dysphagia in immunocompetent patients.

Radiologic Procedure	Rating	Comments	RRL*
X-ray biphasic esophagram	8	Endoscopy and biphasic esophagram are both excellent diagnostic tests in this setting. Double contrast and single contrast.
X-ray barium swallow	6	Probably indicated if that is all the patient can do.
X-ray barium swallow modified	4
X-ray pharynx dynamic and static imaging	4
Technetium (Tc)-99m transit scintigraphy esophagus	4
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Variant 4: Retrosternal dysphagia in immunocompromised patients.

Radiologic Procedure	Rating	Comments	RRL*
X-ray biphasic esophagram	8	Endoscopy and biphasic esophagram are both excellent diagnostic tests in this setting. Double contrast and single contrast.
X-ray barium swallow	5
X-ray barium swallow modified	4
X-ray pharynx dynamic and static imaging	3
Technetium (Tc)-99m transit scintigraphy esophagus	2
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Summary of Literature Review

"Dysphagia" according to Stedman's Medical Dictionary and Dorland's Medical Dictionary is defined as "difficulty in swallowing." Dysphagia is also a symptom, defined as the "subjective awareness of swallowing difficulty during passage of a liquid or solid bolus from the mouth to the stomach." As a symptom, it is usually indicative of an abnormality in the function or structure of the organs involved in swallowing or those involved in swallowing, breathing, and speech interaction. However, it is important to be aware of the fact that a person may have a swallowing problem but not be symptomatic. In one recent examination of 2,000 videofluoroscopic studies, 51% of the patients aspirated, but of those who did, over half had no protective cough (silent aspiration).

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-contrast and single-contrast static images to assess structural abnormalities such as rings, strictures, or 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. For example, in the immediate postoperative scenario, the choice of contrast may include water-soluble contrast such as diatrizoate meglumine and diatrizoate sodium solution (Gastrografin®) or iohexol (Omnipaque®), rather than barium sulfate.

Clinical Perspective

Many patients with dysphagia can subjectively localize a sensation of blockage or discomfort to the throat or retrosternal 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 oral cavity, pharynx, esophagus, and gastric cardia is appropriate for patients with unexplained pharyngeal dysphagia.

Other patients may have retrosternal 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 often 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 and the presence of a hiatal hernia.

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:

1. Oropharyngeal dysphagia with an attributable cause
2. Unexplained oropharyngeal dysphagia
3. Retrosternal dysphagia in immunocompetent patients
4. Retrosternal 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 to assess abnormalities of both the oral phase of swallowing (e.g., difficulty propelling the bolus) and the pharyngeal phase (e.g., laryngeal penetration, tracheal aspiration, cricopharyngeal dysfunction). It has been shown that the risk of developing aspiration pneumonia is directly related to the degree of swallowing dysfunction on video fluoroscopic studies. The patient may be given high-density or 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 chin-tuck 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 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, particularly if no abnormalities are found in the pharynx to account for their symptoms (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.

Retrosternal Dysphagia in Immunocompetent Patients

The biphasic esophagram is a valuable technique for evaluating retrosternal 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 one 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 esophageal motility disorders (e.g., achalasia, diffuse esophageal spasm) in comparison to esophageal manometry. Occasionally, barium studies may even reveal dysmotility not seen at manometry (e.g., some patients with the beaklike distal esophageal narrowing of achalasia are found to have complete relaxation of the lower esophageal sphincter on manometry). In any case, when a significant esophageal motility disorder is detected on a barium study, manometry may be performed to further elucidate the nature of this motility disorder. A subcategory of the "retrosternal dysphagia in the immunocompetent patient" is known or suspected achalasia, pretreatment or post-treatment. Specific protocols to assess emptying are useful. It should be determined that the patient does not aspirate thin liquids before large quantities of barium are given. Alternatively, radionuclide esophageal transit scintigraphy is a simple, noninvasive, and quantitative test of esophageal emptying.

Retrosternal 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 human immunodeficiency virus (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, or 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.

Relative Radiation Level Designations

Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
	<0.1 mSv	<0.03 mSv
	0.1-1 mSv	0.03-0.3 mSv
	1-10 mSv	0.3-3 mSv
	10-30 mSv	3-10 mSv
	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as NS (not specified).

Algorithms were not developed from criteria guidelines.

The recommendations are based on analysis of the current literature and expert panel consensus.

Selection of appropriate radiologic imaging procedures for diagnosis and evaluation of patients with dysphagia

Relative Radiation Level (RRL)

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults. Additional information regarding radiation dose assessment for imaging examinations can be found in the American College of Radiology (ACR) Appropriateness Criteria® Radiation Dose Assessment Introduction document (see "Availability of Companion Documents" field).

The American College of Radiology (ACR) Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those exams generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the U.S. Food and Drug Administration (FDA) have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Gastrointestinal Imaging

Panel Members: Bronwyn Jones, MD (Principal Author); Bob W. Gayler, MD (Research Author); Max Paul Rosen, MD, MPH (Panel Chair); Michael A. Blake, MB, BCh (Panel Vice-Chair); Mark E. Baker, MD; Brooks D. Cash, MD; Jeff L. Fidler, MD; Thomas H. Grant, DO; Frederick L. Greene, MD; Douglas S. Katz, MD; Tasneem Lalani, MD; Frank H. Miller, MD; William C. Small, MD, PhD; Gary S. Sudakoff, MD; David M. Warshauer, MD; Judy Yee, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Levine MS, Bree RL, Rosen MP, Foley WD, Gay SB, Grant TH, Heiken JP, Huprich JE, Lalani T, Miller FH, Ros PR, Sudakoff GS, Greene FL, Rockey DC, Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® dysphagia. [online publication]. Reston (VA): American College of Radiology (ACR); 2007. 6 p. [35 references]

The appropriateness criteria are reviewed biennially and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site.

Print copies: Available from the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

The following are available:

• ACR Appropriateness Criteria®. Overview. Reston (VA): American College of Radiology; 2 p. Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site.
• ACR Appropriateness Criteria®. Literature search process. Reston (VA): American College of Radiology; 1 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site.
• ACR Appropriateness Criteria®. Evidence table development. Reston (VA): American College of Radiology; 4 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site.
• ACR Appropriateness Criteria®. Radiation dose assessment introduction. Reston (VA): American College of Radiology; 2 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site.

None available

This summary was completed by ECRI on March 19, 2001. The information was verified by the guideline developer on March 29, 2001. This summary was updated by ECRI on July 31, 2002. The updated information was verified by the guideline developer on October 1, 2002. This summary was updated by ECRI on November 17, 2005. This summary was updated by ECRI Institute on June 17, 2009. This NGC summary was updated by ECRI Institute on December 1, 2010.

Instructions for downloading, use, and reproduction of the American College of Radiology (ACR) Appropriateness Criteria® may be found on the ACR Web site .