Dysphagia

Question 1

What is dysphagia?

Answer 1

Difficulty swallowing

Question 2

What is odynophagia?

Answer 2

Pain on swallowing

Question 3

What sorts of foods often cause dysphagia?

Answer 3

Often solids

Can be both solids and liquids

Question 4

Is the level of obstruction actually at where it is indicated?

Answer 4

Generally lower

Question 5

What are oropharyngeal causes of dysphagia?

Answer 5

Usually neuromuscular dysfunction
- Stroke
- Head and neck surgery/radiotherapy
Structural disorders
- Stricture
- Web
- Pharyngeal pouch/diverticulum

Question 6

What are oesophageal causes of dysphagia?

Answer 6

Stricture
- Reflux disease
- Malignant
- Extrinsic compression
Functional
- Achalasia
- Dysmotility - diffuse oesophageal spasm/scleroderma
- Pouches/diverticula

Question 7

What are the questions on history to ask about the dysphagia?

Answer 7

Does patient have dysphagia?
Oropharyngeal vs oesophageal
Structural vs functional
Underlying cause

Question 8

What is globus pharyngis?

Answer 8

Feeling of lump in one’s throat

Question 9

Is globus pharyngis a true dysphagia?

Answer 9

No

Question 10

Where can the level of swallowing difficulty be? Is this a reliable question to ask the patient?

Answer 10

Neck
Retrosternal
Unreliable

Question 11

What can sudden onset of dysphagia be?

Answer 11

Bolus obstruction

CVA

Question 12

What can dysphagia that progresses over weeks to months be?

Answer 12

Malignancy
Stricture
Achalasia

Question 13

What can dysphagia that is intermittent and non-progressive be?

Answer 13

Benign stricture
Web
Hiatus hernia

Question 14

What can dysphagia that is intermittent and progressive be?

Answer 14

Functional; eg:

• Achalasia
• Scleroderma
• Spasm

Question 15

What can dysphagia for solids be?

Answer 15

Likely structural problem

Question 16

What can dysphagia for liquids be?

Answer 16

Likely functional problem

Question 17

What can associated symptoms suggest about the cause of achalasia?

Answer 17

Weight loss 
- Malignancy
- Achalasia
Long-term reflux
- Peptic stricture
Associated disease
- Scleroderma
- CVA
Aspiration
- Neuromuscular issues; eg:
   - CVA
   - Achalasia

Question 18

What is relevant past history in the context of dysphagia?

Answer 18

Reflux
CVA
Neurological disorders
Caustic ingestion > Hx of self harm

Question 19

What are the significant signs on examination for dysphagia?

Answer 19

Often aren’t any

Question 20

What should you look for in examination for dysphagia?

Answer 20

General appearance
- Wasted > ?malignancy
Periphery
- Scleroderma
Head and neck
- Lymph nodes
- Previous surgery
- Gurgling pouch in neck
Neurological function

Question 21

What are the investigations for oropharyngeal dysphagia?

Answer 21

Video swallow

• Often done by speech pathologist post-stroke
• Uses contrast
• Provides functional info
• Can ID pharyngeal pouch

Question 22

What are the investigations for oesophageal dysphagia?

Answer 22

Gastroscopy
- Can ID structural abnormality
- May be therapeutic; eg:
   - Dilate stricture
   - Remove foreign body
Barium swallow
- Quick
- Easy access
- Not easy to see gastro-oesophageal junction
- Often doesn't give structural diagnosis
- Can give info on functional problem
CT
- Assessment of
   - Large hiatus hernia
   - Extrinsic compression
Oesophageal manometry
- Assessment of
   - Achalasia
   - Diffuse oesophageal spasm
Endoscopic US
- Characterises lesions in wall; eg: gastrointestinal stromal tumours (GIST)

Question 23

What causes a pharyngeal pouch?

Answer 23

Dysfunction/spasm of upper oesophageal sphincter

Question 24

What is a pharyngeal pouch?

Answer 24

Part of oesophagus herniates between 2 muscles in pharynx

Question 25

What are the clinical features of a pharyngeal pouch, other than dysphagia?

Answer 25

Gurgling in neck | Brings up previously eaten foods

Question 26

How is pharyngeal pouch diagnosed?

Answer 26

Barium swallow | Gastroscopy

Question 27

What is the treatment for a pharyngeal pouch?

Answer 27

Cricopharyngeal myotomy via - Open procedure in neck - Endoscopic transoral myotomy

Question 28

What is the surveillance for Barrett's oesophagus?

Answer 28

Gastroscopy every 2 years

Question 29

How many people with Barrett's oesophagus go on to develop cancer?

Answer 29

1%

Question 30

What are the common types of oesophageal cancer that can develop, and in what proportions?

Answer 30

Adenocarcinoma = 50% | Squamous cell carcinoma = 50%

Question 31

What are the staging investigations for oesophageal cancer?

Answer 31

``` Endoscopy and biopsy CT scan chest/abdomen - good for T stage PET scan - assess metastatic disease Staging laparoscopy - Especially for lower third cancers - Lavage with 1L saline > suction > spin fluid down > analyse cells centrifuged for malignancy Bronchoscopy for mid-oesophageal tumours ```

Question 32

What is the treatment for oesophageal cancer?

Answer 32

Surgery - aim to resect, if not locally advanced, and no metastastis Chemo/radiotherapy

Question 33

What are the clinical features for reflux related stricture, other than dysphagia?

Answer 33

Hx of reflux/heartburn

Question 34

What is the investigation for reflux related stricture?

Answer 34

Gastroscopy - Confirms diagnosis - Excludes malignancy

Question 35

What is the treatment for reflux related stricture?

Answer 35

``` Dilate stricture at time of gastroscopy - Balloon dilatation Treat cause - PPI - Anti-reflux operation - fundoplication ```

Question 36

What are the clinical features of a large hiatus hernia, other than dysphagia?

Answer 36

``` Lengthy Hx Intermittent symptoms possible May not have heartburn May have vomiting/regurgitation feel hold up sensation Full and bloated, especially after big meal ```

Question 37

What are the investigations for a large hiatus hernia?

Answer 37

Gastroscopy | CT/barium swallow

Question 38

What is the treatment for a large hiatus hernia?

Answer 38

Symptomatic in fit patient > laparoscopic repair | Asymptomatic in elderly/unfit patient > conservative management

Question 39

What is achalasia?

Answer 39

Failure of relaxation of oesophageal sphincter

Question 40

What are the clinical features of achalasia, other than dysphagia?

Answer 40

``` Lengthy Hx Progressive: solids > liquids Weight loss Odynophagia Regurgitation Malnutrition ```

Question 41

What are the investigations for achalasia?

Answer 41

Gastroscopy - exclude cancer Oesophageal manometry - gold standard Barium swallow can be helpful

Question 42

What is the treatment for achalasia?

Answer 42

Laparoscopic cardiomyotomy = divide lower oesophageal sphincter - Dissect muscle without dissecting mucosa Oesophageal dilatation can occasionally be used - not permanent solution

Question 43

When should you consider anti-reflux surgery?

Answer 43

Failed medical therapy Complications despite adequate treatment Preference to avoid drugs Intolerance of therapy

Question 44

What is a Nissen fundoplication?

Answer 44

Pull oesophagus into abdomen | Suture fundus of stomach around bottom of oesophagus

Question 45

What are the side-effects of anti-reflux surgery?

Answer 45

Inability to burp/vomit Increased flatus Bloating

Question 46

What is the algorithm if you see a benign stricture on gastroscopy?

Answer 46

Dilate > - PPI - Consider fundoplication

Question 47

What is the algorithm if you see a malignant stricture on gastroscopy?

Answer 47

Staging investigations > - Advanced disease > chemo/radiotherapy - Early disease > - Surgery - Neo-adjuvant chemotherapy > surgery