ACR Appropriateness Criteria® Dysphagia EVIDENCE TABLE Reference

Study Type

Patients/ Events N/A

Study Objective (Purpose of Study) To review the current clinical and laboratory assessments of dysphagia and the emerging techniques that have been developed recently that allows better understanding of esophageal motor function. To determine the prevalence of dysphagia in primary care patients.

1.

Kuo P, Holloway RH, Nguyen NQ. Current and future techniques in the evaluation of dysphagia. J Gastroenterol Hepatol 2012; 27(5):873-881.

Review/OtherDx

2.

Wilkins T, Gillies RA, Thomas AM, Wagner PJ. The prevalence of dysphagia in primary care patients: a HamesNet Research Network study. J Am Board Fam Med 2007; 20(2):144-150.

Review/OtherDx

947 patients

3.

Cook IJ. Oropharyngeal dysphagia. Gastroenterol Clin North Am 2009; 38(3):411-431. Garon BR, Sierzant T, Ormiston C. Silent aspiration: results of 2,000 video fluoroscopic evaluations. J Neurosci Nurs 2009; 41(4):178-185; quiz 186-177.

Review/OtherDx

N/A

Review/OtherDx

2,000 patients

Retrospectively study aspiration and silent aspiration to increase the awareness of nursing staffs of the diagnostic pathology groups associated with silent aspiration.

Wilcox CM, Alexander LN, Clark WS. Localization of an obstructing esophageal lesion. Is the patient accurate? Dig Dis Sci 1995; 40(10):2192-2196.

ObservationalDx

139 patients

To determine if patient’s sensation of dysphagia can accurately localize obstructing esophageal lesions.

4.

5.

* See Last Page for Key

To review oropharyngeal dysphagia.

2013 Review

Study Results No results stated in abstract.

Study Quality 4

Of the 947 study participants, 214 (22.6%) reported dysphagia occurring several times per month or more frequently. Those reporting dysphagia were more likely to be women (80.8% women vs 19.2% men, P=.002) and older (mean age of 48.1 in patients with dysphagia vs mean age of 45.7 in patients without dysphagia, P=.001). 64% of patients with dysphagia indicated that they were concerned about their symptoms, but 46.3% had not spoken with their doctor about their symptoms. Logistic regression analyses showed that increased frequency (OR = 2.15, 95% CI, 1.41-3.30), duration (OR = 1.91, CI 1.24-2.94), and concern (OR = 2.64, CI 1.365.12) of swallowing problems as well as increased problems eating out (OR = 1.72, CI 1.19-2.49) were associated with increased odds of having talked to a physician. No results stated in abstract.

4

51% of patients aspirated on the video fluoroscopic evaluation. Of the patients who aspirated, 55% had no protective cough reflex (silent aspiration). The diagnostic pathology groups with the highest rates of silent aspiration were brain cancer, brainstem stroke, head-neck cancer, pneumonia, dementia/Alzheimer, chronic obstructive lung disease, seizures, myocardial infarcts, neurodegenerative pathologies, right hemisphere stroke, closed head injury, and left hemisphere stroke. Patients more accurate in localizing proximal rather than distal lesions, as distal lesions often cause referred dysphagia.

4

4

2

Carucci/Lalani Page 1

ACR Appropriateness Criteria® Dysphagia EVIDENCE TABLE Reference 6.

7.

8. 9.

Logemann JA. Role of the modified barium swallow in management of patients with dysphagia. Otolaryngol Head Neck Surg 1997; 116(3):335-338. Chen YM, Ott DJ, Gelfand DW, Munitz HA. Multiphasic examination of the esophagogastric region for strictures, rings, and hiatal hernia: evaluation of the individual techniques. Gastrointest Radiol 1985; 10(4):311-316. Levine MS, Rubesin SE. Radiologic investigation of dysphagia. AJR 1990; 154(6):1157-1163. Hartl DM, Kolb F, Bretagne E, Marandas P, Sigal R. Cine magnetic resonance imaging with single-shot fast spin echo for evaluation of dysphagia and aspiration. Dysphagia 2006; 21(3):156-162.

10. Kulinna-Cosentini C, Schima W, Lenglinger J, et al. Is there a role for dynamic swallowing MRI in the assessment of gastroesophageal reflux disease and oesophageal motility disorders? Eur Radiol 2012; 22(2):364370.

* See Last Page for Key

Study Type Review/OtherDx

Patients/ Events N/A

Study Objective (Purpose of Study) Reviews role and technique of modified barium swallow in patients with oropharyngeal dysphagia.

ObservationalDx

159 patients

Review/OtherDx

N/A

Review/OtherDx

6 patients

To determine the feasibility of and interest in evaluation of swallowing using cine-MRI in patients with dysphagia and aspiration caused by an abnormal pharyngeal phase of swallow.

ObservationalDx

37 patients

To evaluate the diagnostic value of dynamic MRI swallowing in patients with symptoms of gastroesophageal reflux disease.

Study Results Modified barium swallow can be effective tool in rehabilitation of these patients.

Study Quality 4

To compare radiographic and endoscopic sensitivities in patients with lower esophageal rings.

95% of lower esophageal rings detected by barium esophagography vs 76% by endoscopy. Radiographic examination more accurate.

3

Presents a practical approach for radiologic investigation of dysphagia.

The radiologic examination of the pharynx and esophagus should be tailored according to the nature and location of dysphagia. Cine-MRI using the dry swallow technique is feasible and without risk in patients with clinical aspiration. Cine-MRI is complementary to clinical evaluation of swallowing in patients with an abnormal pharyngeal phase of swallowing resulting from treatment of cancer. MRI results were concordant with pH-metry in 82% (23/28) of patients diagnosed with abnormal oesophageal acid exposure by pHmetry. 5 patients demonstrated typical symptoms of gastroesophageal reflux disease and had positive findings with pH monitoring, but false negative results with MRI. In 4/6 patients (67%), there was a correct diagnosis of oesophageal motility disorder, according to manometric criteria, on dynamic MRI. The overall accuracy of MRI diagnoses was 79% (27/34). A statistically significant difference was found between the size of hiatal hernia, grade of reflux in MRI, and abnormal acid exposure on pH-monitoring.

4

2013 Review

4

3

Carucci/Lalani Page 2

ACR Appropriateness Criteria® Dysphagia EVIDENCE TABLE Patients/ Events 3 patients

Study Objective (Purpose of Study) To perform a single-phase volume scanning and multiphase volume scanning on patients and to create 3D and 4D images to evaluate the feasibility of morphologic and kinematic analysis of swallowing using 320-MSCT.

ObservationalDx

6 patients

To (1) depict normal dynamic swallowing and (2) measure (a) the temporal characteristics of three components of laryngeal closure, ie, true vocal cord (TVC) closure, closure of the laryngeal vestibule at the arytenoid to epiglottic base, and epiglottic inversion, and (b) the temporal relationship between these levels of laryngeal closure and other swallowing events, hyoid elevation, and the pharyngoesophageal segment using 320MSCT.

ObservationalDx

381 patients

To determine relationship between swallowing dysfunction on barium studies and risk of aspiration pneumonia.

The single-phase 3D images clearly and accurately showed the structures involved in swallowing, and the multiphase 3D images were able to show the oral stage to the early esophageal stage of swallowing, allowing a kinematic analysis of swallowing. A reclining chair that allows scanning to be performed with the subject in a semisitting position, which makes swallowing evaluation by 320MSCT applicable not only to research on healthy swallowing but also to the clinical examination of dysphagia patients. The swallowing of a 10-ml portion of honeythick liquid (5% w/v) was examined in 6 healthy volunteers placed in a 45 degrees reclining position. 3D CT images were created in 29 phases at an interval of 0.10 s over a 2.90-s duration. Dynamic swallowing and true vocal cord movement were depicted clearly. The sequence for laryngeal closure was the following: (1) the hyoid started to elevate, (2) the pharyngoesophageal segment opened, (3) true vocal cord closure and closure at the arytenoid to epiglottic base occurred almost simultaneously during the hyoid elevation, and (4) the epiglottic maximum inversion occurred after the hyoid maximum displacement. Likelihood of developing aspiration pneumonia directly related to degree of swallowing dysfunction on barium studies.

Review/OtherDx

N/A

Reviews a radiologic approach for evaluating patients with pharyngeal swallowing disorders.

Both structural and functional abnormalities of the pharynx can be well shown on barium studies.

Reference

Study Type

11. Fujii N, Inamoto Y, Saitoh E, et al. Evaluation of swallowing using 320detector-row multislice CT. Part I: singleand multiphase volume scanning for three-dimensional morphological and kinematic analysis. Dysphagia 2011; 26(2):99-107.

Review/OtherDx

12. Inamoto Y, Fujii N, Saitoh E, et al. Evaluation of swallowing using 320detector-row multislice CT. Part II: kinematic analysis of laryngeal closure during normal swallowing. Dysphagia 2011; 26(3):209-217

13. Pikus L, Levine MS, Yang YX, et al. Videofluoroscopic studies of swallowing dysfunction and the relative risk of pneumonia. AJR 2003; 180(6):1613-1616. 14. Rubesin SE. Oral and pharyngeal dysphagia. Gastroenterol Clin North Am 1995; 24(2):331-352.

* See Last Page for Key

2013 Review

Study Results

Study Quality 4

4

3

4

Carucci/Lalani Page 3

ACR Appropriateness Criteria® Dysphagia EVIDENCE TABLE Reference

Study Type

Patients/ Events 130 patients

Study Objective (Purpose of Study) To determine the prevalence of lower esophageal mucosal rings and to correlate the relationship between these mucosal rings and the presence and anatomic level of symptoms evoked using a marshmallow bolus.

Study Results

15. Smith DF, Ott DJ, Gelfand DW, Chen MY. Lower esophageal mucosal ring: correlation of referred symptoms with radiographic findings using a marshmallow bolus. AJR 1998; 171(5):1361-1365.

Review/OtherDx

16. Schima W, Pokieser P, Schober E, et al. Globus sensation: value of static radiography combined with videofluoroscopy of the pharynx and oesophagus. Clin Radiol 1996; 51(3):177185. 17. Levine MS, Chu P, Furth EE, Rubesin SE, Laufer I, Herlinger H. Carcinoma of the esophagus and esophagogastric junction: sensitivity of radiographic diagnosis. AJR 1997; 168(6):1423-1426. 18. DiPalma JA, Prechter GC, Brady CE, 3rd. X-ray-negative dysphagia: is endoscopy necessary? J Clin Gastroenterol 1984; 6(5):409-411. 19. Halpert RD, Feczko PJ, Spickler EM, Ackerman LV. Radiological assessment of dysphagia with endoscopic correlation. Radiology 1985; 157(3):599-602. 20. Ott DJ, Chen YM, Wu WC, Gelfand DW, Munitz HA. Radiographic and endoscopic sensitivity in detecting lower esophageal mucosal ring. AJR 1986; 147(2):261-265.

ObservationalDx

130 patients

To determine diagnostic value of static images combined with videofluoroscopy vs either technique alone in patients with globus sensation.

ObservationalDx

50 patients

To determine sensitivity of double contrast esophagram in diagnosing cancer of esophagus and esophagogastric junction.

Double contrast esophagography had sensitivity of 96% in diagnosing these tumors.

3

Review/OtherDx

195 patients

To determine if endoscopy increased chances of finding esophageal cancer in patients with radiographic-negative dysphagia.

No cases of esophageal cancer found by endoscopy that had been missed on barium study.

4

ObservationalDx

127 patients

To determine frequency of abnormalities on biphasic esophagrams in patients with dysphagia and correlate with endoscopy.

77% of patients with dysphagia had abnormal barium studies; 3.3% had esophageal cancer; no cancers missed on barium study.

3

ObservationalDx

60 patients

To compare radiographic and endoscopic sensitivities in patients with lower esophageal rings.

95% of lower esophageal rings detected by barium esophagography vs 76% by endoscopy. Radiographic examination more accurate.

3

* See Last Page for Key

2013 Review

Lower esophageal mucosal rings were shown in 26 (20%) of the patients. In 16 (62%) of the 26 patients, a marshmallow bolus became impacted at the ring. The impaction caused dysphagia in 12 (75%) of the 16 patients. In these 12 patients, dysphagia was referred to: 7- in the neck, 2- sternal angle, 2- mid chest, and 1- the lower chest. None of the 12 patients had a pharyngeal or cervical esophageal abnormality that would account for their symptoms. Because proximal referral of symptoms is common in patients with lower esophageal mucosal rings, a thorough radiographic examination of the entire esophagus and esophagogastric region is required regardless of the level of their swallowing complaints. Videofluoroscopy combined with static images revealed significantly more abnormalities in pharynx and esophagus than either technique alone.

Study Quality 4

3

Carucci/Lalani Page 4

ACR Appropriateness Criteria® Dysphagia EVIDENCE TABLE Patients/ Events 90 patients

Study Objective (Purpose of Study) To determine endoscopic sensitivity in detecting peptic esophageal strictures.

ObservationalDx

80 patients

To compare radiology and endoscopy in diagnosis of peptic strictures.

Radiology detected 95% of all strictures.

3

ObservationalDx

172 patients

To correlate radiographic and manometric findings in patients with dysphagia.

Barium studies had overall sensitivity of 89% and specificity of 91% in diagnosing esophageal motility disorders.

3

ObservationalDx

88 patients

Prospective study to correlate videofluoroscopic and manometric findings in patients with dysphagia, chest pain, or scleroderma.

Videofluoroscopy had overall sensitivity of 80% and specificity of 79% in diagnosing esophageal motility disorders.

2

ObservationalDx

21 patients

Retrospective study to evaluate presence of complete lower esophageal sphincter relaxation on manometry in patients with achalasia on barium studies.

Nearly one-third of patients with achalasia on barium studies had complete lower esophageal sphincter relaxation on manometry and symptoms resolved in all after treatment for achalasia.

3

ObservationalDx

23 patients

To define a simple technique for timing a barium swallow by which radiologists can assess esophageal emptying in patients with achalasia before and after minimally invasive therapy.

There was no statistically significant difference between the percentage of emptying as measured on the digitized images and the H x W calculations or qualitative emptying percentage. Interobserver agreement for the area evaluated on the digitized films as well as the H x W measurements and qualitative estimates of emptying was almost perfect (the correlation coefficients being 0.99, 0.87, and 0.93, respectively). Both qualitative assessment and estimated change in area based on H x W measurements of the barium column are accurate methods of estimating esophageal emptying.

3

Reference

Study Type

21. Ott DJ, Chen YM, Wu WC, Gelfand DW. Endoscopic sensitivity in the detection of esophageal strictures. J Clin Gastroenterol 1985; 7(2):121-125. 22. Ott DJ, Gelfand DW, Lane TG, Wu WC. Radiologic detection and spectrum of appearances of peptic esophageal strictures. J Clin Gastroenterol 1982; 4(1):11-15. 23. Ott DJ, Richter JE, Chen YM, Wu WC, Gelfand DW, Castell DO. Esophageal radiography and manometry: correlation in 172 patients with dysphagia. AJR 1987; 149(2):307-311. 24. Schima W, Stacher G, Pokieser P, et al. Esophageal motor disorders: videofluoroscopic and manometric evaluation--prospective study in 88 symptomatic patients. Radiology 1992; 185(2):487-491. 25. Amaravadi R, Levine MS, Rubesin SE, Laufer I, Redfern RO, Katzka DA. Achalasia with complete relaxation of lower esophageal sphincter: radiographicmanometric correlation. Radiology 2005; 235(3):886-891. 26. de Oliveira JM, Birgisson S, Doinoff C, et al. Timed barium swallow: a simple technique for evaluating esophageal emptying in patients with achalasia. AJR 1997; 169(2):473-479.

ObservationalDx

* See Last Page for Key

2013 Review

Study Results Barium studies detected 95% of all strictures. Endoscopy and radiology are equally effective and complementary methods.

Study Quality 3

Carucci/Lalani Page 5

ACR Appropriateness Criteria® Dysphagia EVIDENCE TABLE Patients/ Events 51 patients

Study Objective (Purpose of Study) To assess the ability of TBE to predict symptoms and treatment failure during posttreatment follow-up and to determine whether esophageal emptying as assessed by TBE differs after treatment with pneumatic dilatation or laparoscopic myotomy.

Review/OtherDx

10 patients

To evaluate radionuclide esophageal transit studies for diagnosing esophageal dysmotility in patients with chest pain or dysphagia.

Review/OtherDx

N/A

Reviews role of radionuclide esophageal studies in patients with dysphagia.

Esophageal scintigraphy is a simple, rapid, noninvasive test for assessing esophageal transit and function in a quantifiable way in patients with dysphagia.

4

Review/OtherDx

N/A

Reviews causes of oropharyngeal and esophageal dysphagia.

Advocates barium study for diagnosing these lesions.

4

Review/OtherDx

N/A

Reviews spectrum of abnormalities that cause dysphagia.

Advocates barium radiology as investigation of choice in patients with dysphagia.

4

Review/OtherDx

N/A

To review HIV associated gastrointestinal pathology with emphasis on common endoscopic biopsy diagnoses.

No results stated in abstract.

4

Reference

Study Type

27. Andersson M, Lundell L, Kostic S, et al. Evaluation of the response to treatment in patients with idiopathic achalasia by the timed barium esophagogram: results from a randomized clinical trial. Dis Esophagus 2009; 22(3):264-273.

ObservationalTx

28. Paramsothy M, Goh KL, Kannan P. Oesophageal motility disorders: rapid functional diagnosis using computerised radionuclide oesophageal transit study. Singapore Med J 1995; 36(3):309-313. 29. Stacey B, Patel P. Oesophageal scintigraphy for the investigation of dysphagia: in ans out of favour underused when available. Eur J Nucl Med Mol Imaging 2002; 29(9):1216-1220. 30. Barloon TJ, Bergus GR, Lu CC. Diagnostic imaging in the evaluation of dysphagia. Am Fam Physician 1996; 53(2):535-546. 31. Phillips AJ, Nolan DJ. Radiology of oesophageal dysphagia. Br J Hosp Med 1995; 53(9):458-466. 32. Bhaijee F, Subramony C, Tang SJ, Pepper DJ. Human immunodeficiency virusassociated gastrointestinal disease: common endoscopic biopsy diagnoses. Patholog Res Int 2011; 2011:247923. * See Last Page for Key

2013 Review

Study Results 51 patients with newly diagnosed achalasia were prospectively randomized to pneumatic dilatation (n=26) or laparoscopic myotomy (n=25). Evaluation with TBE was performed before (n=46) and after treatment (n=43). The median interval between treatment and posttreatment TBE was 6 months, and the median follow-up time after the post-treatment TBE was 18 months. Following therapeutic intervention, TBE parameters did not differ significantly between treatment groups. However, significant correlations were found between the height of the barium column at 1 min and the symptom scores at the end of follow-up for 'dysphagia for liquids' (P