66. Dysphagia

Question 1

Causes of dysphagia.

a) Solids > liquids
b) Liquids > solids

Answer 1

a) Obstruction:
- strictures secondary to reflux (history of heartburn)
- pharyngeal pouch
- carcinoma (pharyngeal, oesophageal, stomach)
- oesophagitis, oesophageal rings/webs
- inflammation (tonsillitis, laryngitis, pharyngitis, abscess)

b) Neuro - bulbar palsies: stroke, MND, MG, MS, etc.

Question 2

Red flag symptoms in dysphagia

a) Worrying features
b) 2-week wait criteria for stomach/oesophageal Ca

Answer 2

a) - Progressive dysphagia in an older patient
- Weight loss
- Anaemia
- Nausea and vomiting
- Raised platelet count

b) - Dysphagia at any age; or
- Age >55 with weight loss and: upper abdominal pain, reflux or dyspepsia

Question 3

Common associated symptoms

Answer 3

• Food sticking in the gullet
• Choking, vomiting, regurgitation
• Odynophagia
• Dyspepsia

Question 4

Differentials.

a) History of reflux, non-progressive dysphagia to solids
b) Dysarthria, ptosis, proximal muscle weakness
c) Progressive dysphagia, iron-deficiency anaemia, weight loss
d) Iron-deficiency anaemia, glossitis, oesophageal web
e) Dysphagia to solids, regurgitation, bird beak appearance on barium swallow
f) Swelling of the hands, with thick and hardened skin; Raynaud’s phenomenon
g) Elderly male with dysphagia, choking, regurgitation, weight loss and hallitosis

Answer 4

a) Reflux-associated strictures
b) Myasthenia gravis
c) Oesophageal cancer
d) Plummer-Vinson syndrome (Patterson-Brown-Kelly)
e) Achalasia
f) CREST syndrome

g) Pharyngeal pouch (diagnosed on barium swallow)
- Note: must rule out oesophageal Ca with OGD

Question 5

Investigating dysphagia.

Answer 5

• Bloods: FBC (anaemia), haematinics, CRP/ESR,
• Barium swallow
• Endoscopy + biopsy
• If cancer suspected, 2 week wait rules

Question 6

Oesophageal cancer.

a) Risk factors
b) Histology
c) Clinical features
d) Investigations
e) Management

Answer 6

a) Age, smoking, alcohol, reflux (Barrett’s), strictures, achalasia

b) SCC - smoking and alcohol big risk factors
AC - Barrett’s precursor; chronic reflux, inflammation, smoking and alcohol all risks

c) Dysphagia, weight loss, loss of appetite, nausea and vomiting; symptoms of GI blood loss (e.g. melaena) and iron-deficiency anaemia, retrosternal pain

d) - Bloods: FBC, UEs, CRP/ESR, LFTs
- Urgent upper GI endoscopy (2ww) + biopsy
- Staging: CT chest/abdomen +/- PET scan

e) - If early - resection - possibly curative
- Chemoradiotherapy
- Stenting to help strictures
- Pain relief

Question 7

Stomach cancer.

a) Risk factors
b) Histology
c) Clinical features
d) Features of advanced disease
e) Investigations
f) Management
g) What can be given to stimulate appetite?

Answer 7

a) Age, smoking, h. pylori, pernicious anaemia, atrophic gastritis, poor diet, male sex
b) Most are adenocarcinomas; ~5% lymphoma
c) Dyspepsia, weight loss, vomiting, dysphagia and anaemia; abdominal pain
d) Epigastric mass, hepatomegaly, jaundice, ascites, Virchow’s node

e) - Bloods: FBC, ESR, LFTs
- 2 week wait: upper GI endoscopy + biopsy

f) Surgery +/- chemoradiotherapy
g) Corticosteroids