What is the most likely cause of acute dysphagia to both solids and liquids in an elderly patient?

Acute Dysphagia to Both Solids and Liquids in an Elderly Patient

In an elderly patient presenting with acute-onset dysphagia to both solids and liquids simultaneously, a cerebrovascular accident (stroke) is the most likely diagnosis. 1, 2, 3

Clinical Reasoning

Pattern Recognition: The Key Diagnostic Feature

The simultaneous onset of dysphagia to both solids AND liquids is the critical distinguishing feature in this case:

• Dysphagia to both consistencies from onset strongly indicates a neuromuscular/motility problem rather than mechanical obstruction 1, 2
• Progressive dysphagia that begins with solids only and later includes liquids suggests mechanical obstruction (tumor, stricture), whereas simultaneous involvement points to dysmotility or neurologic causes 1, 2

Why Stroke is Most Likely

Acute stroke is the most common cause of oropharyngeal dysphagia presenting with difficulty swallowing both solids and liquids 1, 4, 3:

• The 2-day acute onset strongly favors a vascular event over chronic progressive conditions 3, 5
• Stroke causes pharyngeal motor dysfunction and delayed swallow initiation, affecting both liquid and solid boluses equally 6
• Vocal cord mobility is commonly reduced after acute stroke, impairing airway protection and causing choking episodes 6
• The unremarkable physical exam does not exclude stroke, as dysphagia can be the presenting or isolated manifestation 1, 6

Why Other Options Are Less Likely

Achalasia is excluded by the acute presentation:

• Achalasia classically presents with simultaneous solid and liquid dysphagia, BUT it develops gradually over months to years, not acutely over 2 days 1, 2
• This is a chronic esophageal motility disorder, not an acute neurologic event 2

Esophageal neoplasm is excluded by the pattern:

• Tumors cause progressive dysphagia that begins with solids only, then progresses to include liquids as the obstruction worsens 1, 2
• The simultaneous involvement of both consistencies from onset argues strongly against mechanical obstruction 2

Foreign body is excluded by history and duration:

• Foreign body impaction typically presents with sudden, complete dysphagia immediately after eating, not progressive difficulty over 2 days 3
• The patient would likely recall a specific choking episode or food impaction event 3

Critical Clinical Pitfalls

Silent aspiration occurs in 55% of stroke patients without a protective cough reflex, making clinical examination alone insufficient 2, 4:

• The "unremarkable exam" in this case is misleading—absence of obvious neurologic findings does not exclude stroke-related dysphagia 1, 6
• Multiple swallowing attempts and mild choking episodes are red flags for aspiration risk 4, 3

Older adults have higher rates of silent aspiration than younger patients, reducing the reliability of bedside evaluations 1, 2

Immediate Next Steps

Keep the patient NPO (nothing by mouth) until formal swallowing evaluation is completed, given clear signs of aspiration risk 4:

• The choking episodes indicate failed airway protection 6
• Aspiration pneumonia is a life-threatening complication that must be prevented 1, 5

Obtain urgent neuroimaging (CT or MRI brain) to evaluate for acute stroke 3, 5:

• Even with an unremarkable general physical exam, acute dysphagia warrants stroke evaluation 6

Request videofluoroscopic swallow study (modified barium swallow) or fiberoptic endoscopic evaluation of swallowing (FEES) to assess swallowing mechanics and aspiration risk 1, 4, 7:

• These instrumental assessments are essential because clinical examination misses the majority of aspiration events 2, 4