6. Dysphagia

Question 1

What is dysphagia?

Answer 1

• Difficulty swallowing

can be high or low dysphagia

high is immediately after swallowing

low is a few seconds after swallowing

Question 2

What is odynophagia?

Answer 2

• Painful swallowing
• often due to infection

Question 3

What is globus?

Answer 3

• Common sensation of a lump in the throat without dysphagia
• completely benign

Question 4

What are the differentials for dysphagia?

Answer 4

• organise dysphasia into high and low
• then think if the mechanism is structural or functional

Question 5

What are the neurological causes of dysphagia?

Answer 5

• Achalasia, myasthenia gravis, oesophageal spasm

Question 6

What are the main structural causes of dysphagia?

Answer 6

• Pharyngeal pouch, stricture, and oesophageal cancer

Question 7

What 3 things should you establish in the presenting complaint for dysphagia?

Answer 7

• Duration-

short (days to weeks) suggests cancer

longer suggests chronic motility disorders eg. achalasia

• Is it progressive or intermittent

progressive suggest stricture

intermittent suggests motility disorder

• Does dysphagia occur with solids, fluids, or both?

if the patient is ok with fluids but not solids this means mechanical

if the patient finds fluids more difficult than solids this suggests motility disorder

absolute dysphagia suggests stuck food bolus, if this happens repeatedly might be malignancy or stricture

Question 8

What causes of dysphagia occurs with solids only usually?

Answer 8

• Strictures, may be benign or malignant

Question 9

What causes of dysphagia occurs with fluids only?

Answer 9

• Motility disorder like achalasia

Question 10

What causes of dysphagia occurs with solids and fluids?

Answer 10

Severe strictures, cancer

Question 11

What associated symptoms should you ask about in someone with dysphagia?

Answer 11

• coughing?

choking might suggest Parkinson’s or stroke

if coughing occurs sometime after swallowing it suggests achalasia or GORD

• halitosis? gurgling?

this occurs in patients with a pharyngeal pouch

• heartburn?

this is related to reflux disease with or without a stricture

• weight loss

this is a RED FLAG for oesophageal cancer

Question 12

What PMHx is relevant in someone with dysphagia?

Answer 12

• GORD and peptic ulcers
• these both predispose to strictures

Question 13

What drugs can contribute to dysphagia?

Answer 13

• Calcium channel blockers and nitrates- relax smooth muscle and can exacerbate reflux symptoms
• NSAIDs, aspirin, steroids, bisphosphonates- predispose to peptic ulceration

Question 14

What 5 features are relevant on examination in someone with dysphagia?

Answer 14

• Cranial nerve pathology - might suggest functional dysphagia
• Signs of GI malignancy- virchow’s node
• Neck mass - this might be a pharyngeal pouch
• Features of CREST syndrome
• Koilonychia- suggests severe iron deficiency anaemia which can cause Plummer–Vinson syndrome

Question 15

What are 4 of the main investigations for dysphagia?

Answer 15

• Barium swallow

​Barium swallow is useful in investigating patients who may have a high lesion.

It is also indicated in patients with features suggesting achalasia

• endoscopy

first-line investigation for low dysphagia.

• videofluoroscopy

a modified form of a barium swallow, speech therapist observes the swallowing technique

high dysphasia

• manometry

assesses the pressure in the lower oesophageal sphincter

key investigation in diagnosing a motility disorder

Question 16

treatments for achalasia?

Answer 16

• Pneumatic balloon dilatation
• Surgical (Heller’s) myotomy

(longitudinal incision of the muscle fibers of the distal esophagus)

• Botox injections

(favored in patients unsuited to interventional therapy)

• Drugs

( calcium-channel blockers and/or nitrates)