Acute Dysphagia

Question 1

A 72-year-old woman presents with acute difficulty with swallowing. What are the differential diagnoses, investigations and management?

Impression/DDx/Goals

Answer 1

Impression:
Likely this presentation represents a form of dysphagia. Given patients age, important DDx to consider/ rule out include;
- Stroke, foreign body are most likely given acute onset
- Malignancy (lymphoma, oesophageal carcinoma)
Otherwise, DDx for dysphagia can be grouped into functional and obstructive causes
Obstructive:
- Masses (oesophageal ca, lung ca)
- Rings, strictures, webs
Functional
- Scleroderma
- Achalasia
- Primary oesophageal motility disorder

Goals of management:

• Identify underlying aetiology of dysphagia
• Assess for risk of/ existing complications (malnutrition, aspiration pneumonia; as this will guide whether patient needs admission or not

Question 2

Dysphagia - History

Answer 2

History:

• Sx: characterise difficulty swallowing (oropharyngeal vs oesophageal), what they have recently eaten, natural history of illness, systemic features of malignancy, other stroke symptoms, pain history, solids vs liquids (degree of dysphagia)
• RISK: CVD risk profile, fam hx, previous episodes
• PHX: strokes, cardiac disease, autoimmune disease
• SNAP

Question 3

Dysphagia - Examination

Answer 3

Exam:

• Neurological exam (cranial, UL/LL)
• Swallow assessment (OT/physio/speech path)
• Lymph nodes, haematological exam (spleen etc)
• Systems review

Question 4

Dysphagia - Investigations

Answer 4

Investigations:
Specific tests:
- Oesophageal manometry
- Upper endoscopy +/- biopsy etc
- Barium swallow (not in the acute setting)
Otherwise, may require stroke work-up.

Bedside: Obs, sputum sample?
Bloods: FBC, UEC, CVD risk profile (HbA1c, lipid panel, BSL), scleroderma autoimmune panel
Imaging: If ?stroke, then CTB

Question 5

Dysphagia - Management

Answer 5

Highly dependent on underlying aetiology.
For this elderly woman with swallowing problems, priority would be to reduce risk of complication:
- Swallow assessment
- NBM, use NG feeds/TPN as req.
- Appropriate dispositioning: admission if not safe for home, or outpatients
- consider NG tube insertion, stomach decompression

Long-term

• speech path
• physio

Specific management:

• foreign body: gastro consult and endoscopy for retrieval
• Stroke: stroke pathway, optimise cardiovascular risk factors
• Malignancy: organise MDT
• Scleroderma: Rheum, pharmacological management