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So ... what bought you here today > 6. Dysphagia > Flashcards

6. Dysphagia Flashcards

1
Q

Define dysphagia.

A

Difficulty swallowing

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2
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

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3
Q

What is odynophagia?

A

Painful swallowing

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4
Q

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

A

Malignancy

Infection (more common)

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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

Other than anatomically, how else is dysphagia classified?

A

Functional

Structural

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7
Q

List some functional differentials for high dysphagia

A

Stroke
Parkinson’s Disease

Less common:
Multiple Sclerosis 
Myotonic Dystrophy
Motor Neurone Disease 
Myasthenia Gravis
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8
Q

List some structural differentials for high dysphagia

A

Cancer
Pharyngeal Pouch
Cricopharyngeal Bar

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9
Q

List some functional differentials for low dysphagia

A 
Achalasia 
Chagas Disease 
Nutcracker Oesophagus 
Limited Cutaneous Systemic Sclerosis 
Diffuse Oesophageal Spasm 
Infective and Eosinophilic Oesophagis
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10
Q

List some structural differentials for low dysphagia

A 
Cancer Stricture 
Foreign Body 
Plummer-Vinson Syndrome
Post-Fundoplication 
Mediastinal Mass
Retrosternal Goitre 
Bronchial Carcinoma
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11
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?

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12
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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13
Q

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

A

Motility disorders (e.g. achalasia)

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14
Q

Which cause does progressive dysphagia suggest?

A

Gradually growing stricture (could be malignant or benign)

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15
Q

What cause does intermittent dysphagia suggest?

A

Motility disorder

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16
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
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17
Q

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

A

Motility disorder

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

What does coughing immediately after swallowing suggest?

A

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

20
Q

What does coughing some time after a meal suggest?

A

Regurgitation of food

21
Q

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

A

Achalasia

22
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)

23
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

24
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)

25
Q

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

A

These symptoms are associated with GORD

26
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

27
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

28
Q

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

A 
Calcinosis
Raynaud’s Phenomenon
Oesophageal Dysmotility 
Sclerodactyly
Telangiectasia
29
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

30
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)

31
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)

32
Q

What is the first-line investigation for high dysphagia?

A

Barium Swallow

33
Q

What is the first-line investigation for low dysphagia?

A

OGD

34
Q

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

A

Videofluoroscopy

35
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

36
Q

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

A

Spiral CT Chest/Abdomen
PET
Endoscopic Ultrasound
Laparoscopy

37
Q

What is the main treatment for oesophageal cancer?

A

Oesophagectomy

38
Q

What percentage of oesophageal cancer patients are UNsuitable for surgery?

A

60-70%

39
Q

Define achalasia.

A

Failure of relaxation of the lower oesophageal sphincter

40
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

41
Q

List some treatment options for achalasia.

A

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

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