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Oxford Clinical Cases > Dysphagia > Flashcards

Dysphagia Flashcards

1
Q

What is odynophagia?

A

Painful swallowing

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2
Q

What can cause hoarseness of the voice in patients with dysphagia?

A

Vocal cord dysfunction due to involvement of the recurrent laryngeal nerve (e.g. compression by a pancoast lung tumour)

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3
Q

Which cause does progressive dysphagia suggest?

A

Gradually growing stricture (could be malignant or benign)

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4
Q

Why is it important to enquire about rheumatological symptoms?

A

Rheumatological signs may suggest that limited cutaneous systemic sclerosis is the cause of the dysphagia

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5
Q

What is globus?

A

Common sensation of having a lump in one’s throat without true dysphagia This is a benign condition

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6
Q

What are the five main features of limited cutaneous systemic sclerosis?

A

Calcinosis Raynaud’s Phenomenon Oesophageal Dysmotility Sclerodactyly Telangiectasia

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7
Q

What is the first-line investigation for low dysphagia?

A

OGD

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8
Q

Define achalasia.

A

Failure of relaxation of the lower oesophageal sphincter

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9
Q

List some differentials for low dysphagia:

A
  • Functional Achalasia Chagas Disease Nutcracker Oesophagus Limited Cutaneous Systemic Sclerosis Diffuse Oesophageal Spasm Infective and Eosinophilic Oesophagis - Structural Cancer Stricture Foreign Body Plummer-Vinson Syndrome Post-Fundoplication Mediastinal Mass Retrosternal Goitre Bronchial Carcinoma
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10
Q

Describe the duration of symptoms that is typically associated with oesophageal cancer.

A

Cancer is usually associated with a relatively short history (days/weeks) because the cancer will reach a size at which symptoms begin to appear rapidly

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11
Q

What does coughing some time after a meal suggest?

A

Regurgitation of food

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12
Q

Why is it important to enquire about neurological symptoms?

A

Neurological signs may indicate that functional dysphagia (e.g. due to stroke, Parkinson’s disease etc) is more likely

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13
Q

List some imaging modalities that may be used to stage oesophageal cancer.

A

Spiral CT Chest/Abdomen PET Endoscopic Ultrasound Laparoscopy

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14
Q

Physical examination is rarely useful for dysphagia. However, there are five main features that are important to check for. What are they?

A

Cranial nerve pathology Signs of GI malignancy (e.g. Troisier’s sign, cachexia) Neck mass (e.g. large pharyngeal pouch, retrosternal goitre) Features of CREST syndrome Koilonychia (associated with Plummer-Vinson syndrome)

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15
Q

Name a type of modified barium swallow that is sometimes used to investigate patients with functional high dysphagia.

A

Videofluoroscopy

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16
Q

Which important investigation is used to differentiate between different types of motility disorder?

A

Manometry – assesses the pressures in the lower oesophageal sphincter and the peristaltic wave

17
Q

What are the likely causes of chronic dysphagia lasting months/years?

A

Motility disorders (e.g. achalasia)

18
Q

What does absolute dysphagia to solids, liquids and saliva suggest?

A

Foreign body obstruction (e.g. a bolus of food stuck in the oesophagus)

19
Q

List some important questions to ask about the history of presenting complaint.

A

How long has the dysphagia been around for? Has the dysphagia been progressive or persistent? Has the dysphagia been accompanied by a cough? Has there been any gurgling or dysphonia? Is the dysphagia to solid, liquids or both? Has there been any halitosis? Has there been any heartburn or waterbrash? Has there been any unintentional weight loss? Have there been any neurological symptoms? Have there been any rheumatological symptoms?

20
Q

What might halitosis in a patient with dysphagia suggest?

A

This occurs if food gets stuck in the oropharynx (e.g. in a pharyngeal pouch)

21
Q

Define dysphagia.

A

Difficulty swallowing

22
Q

Broadly speaking, what are the two main causes of odynophagia?

A

Malignancy Infection (more common)

23
Q

What are the two most important conditions to enquire about with regards to the patient’s past medical history? Explain why.

A
  • GORD Predisposes to oesophageal cancer and non-malignant strictures - Peptic Ulcer Disease Can lead to scarring and strictures around the gastric cardia and lower oesophagus
24
Q

Other than anatomically, how else is dysphagia classified?

A

Functional Structural

25
Q

What can cause a gurgling noise when patients attempt to speak soon after eating/drinking?

A

Food stuck in a pharyngeal pouch could cause a gurgling noise

26
Q

Describe the typical history of a patient with achalasia.

A

Young patient, no loss of weight, a long history of mild dysphagia to both solids and liquids with no problems coordinating the swallow in the mouth but the food/drink feels like it gets stuck on the way down to the stomach

27
Q

List some important features of the drug history that should be noted.

A

Drugs that relax smooth muscle (e.g. CCBs, nitrated) – exacerbate reflux symptoms Drugs that increase risk of PUD (e.g. NSAIDs, steroids, aspirin, bisphosphonates)

28
Q

List some differentials for high dysphagia:

A
  • Functional Stroke Parkinson’s Disease Multiple Sclerosis Myotonic Dystrophy Motor Neurone Disease Myasthenia Gravis - Structural Cancer Pharyngeal Pouch Cricopharyngeal Bar
29
Q

What is the difference between low dysphagia and high dysphagia?

A

High Dysphagia – patients tend to have problems with initiating the swallow or immediately upon swallowing Low Dysphagia – patients feel that food gets stuck a few seconds after swallowing

30
Q

What is the main treatment for oesophageal cancer?

A

Oesophagectomy

31
Q

What cause does intermittent dysphagia suggest?

A

Motility disorder

32
Q

What does coughing immediately after swallowing suggest?

A

Problem with coordinating the swallow (e.g. due to stroke or Parkinson’s disease)

33
Q

Why is it important to ask whether the patient has experienced heartburn or water brash?

A

These symptoms are associated with GORD

34
Q

List some treatment options for achalasia.

A

Pneumatic balloon dilation Surgical (Heller’s) myotomy Botox injections Drugs (e.g. CCBs and nitrates)

35
Q

What does dysphagia that is worse with fluids than solids suggest?

A

Motility disorder

36
Q

What does nocturnal cough when patients are lying flat and not eating suggest?

A

Achalasia

37
Q

What is the first-line investigation for high dysphagia?

A

Barium Swallow

38
Q

What percentage of oesophageal cancer patients are UNsuitable for surgery?

A

60-70%

39
Q

What does dysphagia to solids but not liquids suggest?

A

Mechanical obstruction (e.g. stricture) NOTE: if this stricture becomes more severe it could cause dysphagia to fluids as well

Oxford Clinical Cases (28 decks)

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