60. Dysphasia, nausea and vomiting

Question 1

What are the differentials for dysphagia?

Answer 1

Malignant stricture
Benign stricture
Pharyngeal/oesophageal/gastric cancer
Extrinsic pressure (lung cancer aortic aneurysms)

Achalasia
Oesophageal spasm
Neurological bulbar palsy

Oesophagitus
Globus

Question 2

What questions are key to ask in dysphagia?

Answer 2

Was there swallowing difficulties or solids and liquids from the start?

Is it difficult to initiate swallowing

Is swallowing painful

Is dysphagia intermittent or getting worse

Does the neck bulge or gurgle on drinking?

Question 3

What information do you expect to illicit when asking if there is difficult swallowing solids and liquids?

Answer 3

Yes: achalasia, CNS or pharyngeal causes

No: solids then liquids ?stricture

Question 4

What do you expect to illicit when you ask is it difficult to initiate a swallowing movement?

Answer 4

Yes: suspect bulbar palsy

Question 5

What do you expect to illicit when you ask is swallowing painful?

Answer 5

Yes: ulceration, malignancy, infection, spasm

Question 6

What do you expect to illicit when you ask is the dysphagia intermittent or getting worse

Answer 6

Intermittent: suspected oesophageal spasm

Constant and worsening: suspect malignant stricture

Question 7

What do you expect to illicit when you ask “does the neck bulge or gurgle on drinking”

Answer 7

Suspect a pharyngeal pouch

Question 8

What does the contents of the vomit tell you about the vomit?

Answer 8

Recognisable food- gastrin stasis

Feculent- small bowel obstruction

Coffee ground vomit- upper GI bleeding, overcalled

Question 9

If a vomit relieves pain, what does that tell you about the vomit?

Answer 9

Peptic ulcer is causing it.

Question 10

What bloods tests would you do after a vomit?

Answer 10

FBC, 
LFT, 
U&E’s, 
Ca levels, 
glucose, 
amylase, 
Arterial blood gas

Question 11

What anti-emitics are used for GI problems?

Answer 11

Cyclizine
Metocloperamide
Prochloperazine

Question 12

What anti emetics are used for vestibular causes?

Answer 12

Cinnarizine

Prochlorperazine

Question 13

What anti-emetics are used for pro-kinetic relief? (Moving the gut motility quickly)

Answer 13

Metoclopramide

Domperidone

Question 14

What other anti-emitics can be used?

Answer 14

Ondansetron

Hyoscine- antimuscarinic also anti-spasmodic and anti-secretory (don’t prescribe with pro-kinetic)

Dexmethasone (unknown method, adjuvant)

Midazolam unknown action, anti-emetic outweighs medazolam