Dysphagia

Question 1

What is dysphagia?

Answer 1

Difficulty in swallowing.

Should prompt urgent investigation to exclude malignancy (unless of short duration, and associated with a sore throat).

Question 2

Dysphagia: key questions to ask

Answer 2

Was there difficulty swallowing solids and liquids from the start? Yes = motility disorder (e.g. achalasia, CNS, or pharyngeal causes). No = solids then liquids, suspect a stricture (benign or malignant).

Is it difficult to initiate a swallowing movement? Yes = suspect bulbar palsy, especially if patient coughs on swallowing.

Is swallowing painful (odynophagia)? Yes = suspect ulceration (malignancy, oesophagitis, viral infection or Candida in immunocompromised, or poor steroid inhaler technique) or spasm.

Is the dysphagia intermittent or is it constant and getting worse? Intermittent = suspect oesophageal spasm. Constant and worsening = suspect malignant stricture.

Does the neck bulge or gurgle on drinking? Yes = suspect a pharyngeal pouch.

Question 3

What are the different causes of dysphagia?

Answer 3

Oral, pharyngeal or oesophageal.
Mechanical or motility related.
Mechanical block: malignant stricture (pharyngeal cancer, oesophageal cancer, gastric cancer); benign strictures (oesophageal web or ring, peptic stricture); extrinsic pressure (lung cancer, mediastinal lymph nodes, retrosternal goitre, aortic aneurysm, left atrial enlargement); pharyngeal pouch.
Motility disorders: achalasia; diffuse oesophageal spasm; systemic sclerosis; neurological bulbar palsy (pseudobulbar palsy, Wilson’s or Parkinson’s disease, syringobulbaia, bulbar poliomyelitis, Chagas’ disease, myasthenia gravis).
Oesophagitis (reflux or Candida/HSV).
Globus (= “I’ve got a lump in my throat”: try to distinguish from true dysphagia).

Question 4

What are the signs of dysphagia?

Answer 4

Is the patient cachectic or anaemic?
Examine the mouth.
Feel for supraclavicular nodes (left supraclavicular node = Virchow’s node, suggests intra-abdominal malignancy.
Look for signs of systemic disease, e.g. systemic sclerosis, CNS disease.

Question 5

What tests are used for reported dysphagia?

Answer 5

FBC (anaemia).
U&E (dehydration).
Upper GI endoscopy +/- biopsy.
If suspicion of pharyngeal pouch consider contrast swallow (+/- ENT opinion).
Video fluoroscopy may help identify neurogenic causes.
Oesophageal manometry for dysmotility.

Question 6

Causes of dysphagia: Diffuse oesophageal spasm

Answer 6

Causes intermittent dysphagia +/- chest pain.

Contrast swallow/ manometry: abnormal contractions.

Question 7

Causes of dysphagia: Achalasia

Answer 7

Coordinated peristalsis is lost and the lower oesophageal sphincter fails to relax (due to degeneration of the myenteric plexus), causing dysphagia, regurgitation, and weight loss.
Characteristic findings on manometry or contrast swallow showing dilated tapering oesophagus.
Treatment: endoscopic balloon dilatation, or Heller’s cardiomyotomy- then proton pump inhibitors. Botulinum toxin injection if a non-invasive procedure is needed (repeat every few months). Calcium channel blockers and nitrates may also relax the sphincter.

Question 8

Causes of dysphagia: Benign oesophageal stricture

Answer 8

Caused by gastro-oesophageal reflux, corrosives, surgery, or radiotherapy.
Treatment: endoscopic balloon dilatation.

Question 9

Causes of dysphagia: Oesophageal cancer associations

Answer 9

Male
GORD
Tobacco
Alcohol
Barrett's oesophagus
Tylosis (palmar hyperkeratosis)
Plummer-Vinson syndrome (post-cricoid dysphagia, upper oesophageal web + iron deficiency.