Dysphagia

Question 1

What is dysphagia?

Answer 1

Difficulty in swallowing

Question 2

Why is dysphagia a red flag symptom?

Answer 2

Dysphagia could indicate a malignancy.
There should be a prompt urgent investigation to exclude malignancy unless dysphagia is of short duration, and associated with a sore throat

Question 3

Causes of dysphagia

Answer 3

Oral, pharyngeal or oesophageal

Question 4

What are the 5 key questions to ask a patient presenting with dysphagia?

Answer 4

1) Was there difficulty swallowing solids and liquids from the start?
Yes: motility disorder (achalasia, CNS or pharyngeal causes)
No: solids then liquids- suspect a stricture (benign or malignant)
2) Is it difficult to initiate a swallowing movement?
Yes: suspect bulbar palsy esp. if patients cough on swallowing
3) Is swallowing painful (odynophagia)?
Yes: suspect ulceration (malignancy, oesophagitis, viral infection, Candida in immunocompromised or poor steroid inhaler technique) or spasm
4) Is the dysphagia intermittent or is it constant and getting worse?
Intermittent: Suspect oesophageal spasm
Constant and worsening- suspect malignant stricture
5) Does the neck bulge or gurgle on drinking?
Yes: Suspect a pharyngeal pouch

Question 5

Other signs seen with dysphagia

Answer 5

Is the patient cachectic or anaemic?
Examine the mouth (ulcers, dry mouth, candida)
Feel for the supraclavicular node (Virchow’s node- intra-abdominal cancer)
Look for signs of systemic disease e.g. systemic sclerosis, CNS disease
General observation (weight loss, jaundice or pallor)
Abdominal examination (scaphoid abdomen, abdominal tenderness, hepatomegaly, previous scars)

Question 6

Which questions should you ask in a Hx of someone with dysphagia?

Answer 6

More details about current symptoms (weight loss, vomiting, bleeding, changes in bowel habits (melaena), pain, symptoms of anaemia)
Background-PMH, FH, DH, LH: NSAIDs, abdominal surgery, smoking, drinking, PPIs, any past endoscopies
ICE

Question 7

Tests to do for a patient with dysphagia

Answer 7

FBC (anaemia)
U&Es (dehydration)
OGD and biopsy
If suspicion of pharyngeal pouch, consider contrast swallow (ENT opinion)
Videofluoroscopy may help identify neurogenic causes
Oesophageal manometry for dysmotility

Question 8

Important conditions that can present with dysphagia

Answer 8

Oesophagitis 
Diffuse oesophageal spasm ( causes intermittent dysphagia and chest pain)
Achalasia 
Benign oesophageal stricture 
Oesophageal cancer

Question 9

What is achalasia?

Answer 9

Coordinated peristalsis is lost and LES fails to relax causing dysphagia, regurgitation and weight loss.
Treatment: endoscopic balloon dilatation or Heller’s cardiomyotomy.

Question 10

What is benign oesophageal stricture?

Answer 10

This is caused by GORD, surgery or radiotherapy.

Treat with balloon

Question 11

Causes of dysphagia (specific conditions)

Answer 11

Mechanical block: 
Malignant stricture (oesophageal cancer, pharyngeal 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)
Motility disorders: 
Achalasia
Diffuse oesophageal spasm 
Systemic sclerosis 
Neurological bulbar palsy: 
-Pseudobulbar palsy 
-Wilson's or Parkinson's disease 
-Syringobulbia 
-Bulbar poliomyelitis 
-Chagas' disease 
-Myasthenia gravis 
Other: 
Oesophagitis (reflux or candida) 
Globus (try to distinguish from dysphagia)