Approach to dysphagia and Plummer Vinson syndrome Flashcards
History taking of dysphagia
- Onset and course
- When did it start? (duration)
- Is it sudden or gradual?
- Is it intermittent or persistent?
- Have you ever experienced this before? - Location
- Food stuck in throat or chest? Point to where it is stuck
> Throat = oropharyngeal; Chest: oesophageal - Pain quality and radiating pain
- Odynophagia: any pain on swallowing?
> inflammation, infection, candidiasis, drug induced
- Severe chest pain on swallowing?
>DES, achalasia, scleroderma
- Radiation of pain - Precipitating factors and food consistency
- Is it difficult to initiate?
> Initiation difficulty = oropharyngeal; midway = oesophageal
- Worse with liquid: oropharyngeal; Worse with solid: oesophageal
- Swallowing difficulty position - supine or upright?
(supine worsens GERD and pericarditis) - Relieving factors
- Any relieving factors or manoeuvre? throat clearing?
- Solid intolerance, does it improve with drinking water? - Reflux or aspiration
- Aspiration symptoms (choking/coughing, nasal or mouth regurgitation): oropharyngeal
- History of aspiration pneumonia
- Reflux (heartburn, acid brash): oesophageal
- Dyspepsia (abdominal discomfort on eating): oesophageal - Associated features and alarm symptoms
(see subsequent card) - Medication history - NSAIDs, steroids, etc
(see subsequent card) - Social history
- Smoking, alcohol - oesophageal carcinoma
- Somatisation (psychiatry) disorders
What are the associated features and alarm symptoms of dysphagia?
- Muscle weakness, previous stroke, dysarthria
- Weakness worse at the end of day: NMJ
- Ptosis, intermittent weakness: MG
- Tight skin over face or hands: scleroderma
- Breathlessness, palpitations: possible mitral stenosis
- Hand colour change with cold temperature: Raynaud
- Nausea, sweating
- Abdominal pain
- Appetite loss and weight loss - malignancy
- Haematemesis or melena
- Change in bowel habit
Differentiating oropharyngeal vs oesophageal dysphagia
Focused examination of dysphagia
A. Facial features
1. Smooth, shiny, tight skin (sclerotic skin) over face and hands
2. Loss of facial wrinkles
3. Perioral puckering, restricted mouth opening
4. Pinched nose
5. Telangiectasia
6. Teeth decay (acid reflux)
B. Hands and nails
1. Smooth, shiny, tight skin (sclerotic skin)
2. Sclerodactyly with flexion deformities
3. Dilated nailfold capillaries
4. Dystrophic nails (IDA)
5. Digital ulcers and gangrene
6. Calcinosis
7. Raynaud’s phenomenon
8. Muscle wasting (malignancy)
C. Neck examination
1. Neck lump, extrinsic compression, goitre
2. Lymphadenopathy
D. Cardiovascular
1. Pericardial rub (pericarditis), loud P2 (PHT), mitral stenosis (dilated LA)
2. Bibasal crepitations (ILD)
E. Neurology
1. UMNL lesion - stroke, brainstem, dysarthria
2. LMNL lesion - Parkinson, MS, muscular dystrophy, myositis
3. NMJ lesion - weakness on repetitive movement
Differential diagnoses of dysphagia
A. Oropharyngeal
1. Bulbar (LMML) /pseudobulbar (UMNL) palsy - difficulty swallowing, chewing, dysphonia, dysarthria
2. Post-infectious - polio, neurosyphilis
3. Oropharyngeal tumour / abscess
4. Oesophageal webs and extrinsic compression as per oesophageal cause
B. Oesophageal
1. Oesophageal/gastric stricture - in chronic GERD
2. Achalasia - chest pain + dysphagia
3. Diffuse oesophageal spasm - severe chest pain + dysphagia, worse with cold water (mimicking ACS)
4. Systemic sclerosis - CREST syndrome
5. Sjogren’s syndrome - dry eyes and mouth
6. Oesophageal ca - malignancy risk, constitutional
7. Oesophagitis - infectious, steroid induced, candidiasis
8. Radiation oesophageal stricture
9. Eosinophilic oesophagitis: allergy, asthma, atopy
10. Extrinsic compression
- Mediastinal lymphadenopathy: PTB, lymphoma, HIV
- LA enlargement: MS
- Cervical spondylosis
- Goitre
11. Globus hysterica - psychiatry, anxiety, psychosis
What are medications that may cause dysphagia?
A. Oesophageal injury
1. Doxycycline
2. Biphosphonates
3. NSAIDs
4. Iron sulphate
B. Lower oesophageal sphincture relaxant
1. Nitrates
2. Calcium antagonist
Investigations for dysphagia
- FBC
- Autoimmune profile (in scleroderma)
- Anti-centromere, SCl-70, RNA polymerase, ANA, RF - ECG
- Barium swallow and fluroscopy
- OGD
- CT TAP
Management plan for dysphagia
- Multidisciplinary - DT, ST, etc (Neurology, Rheumatology, UGI surgery)
- Stop NSAIDs
- PPI for reflux symptoms
- Prokinetics for dysmotility
- Exercise treadmill if suspicious for cardiac disease
- Surgical intervention (if indicated)
Peptic stricture is a complication of acid reflux in 10% patients with GERD.
Symptoms of progressive dysphagia to solid
Endoscopic biopsy confirms stricture is benign
Treatment with endoscopic dilatation
Oesophageal carcinoma
- Squamous cell ca is associated with smoking and alcohol, more common in SEA
- Adenocarcinoma is associated with acid reflux and Barrett’s oesophagus, more common in Western world
Symptoms of rapidly progressive dysphagia and weight loss
Achalasia is the loss of peristalsis in distal oesophagus and failure of lower oesophageal sphincter to relax
Symptoms of complete dysphagia to solid and liquid
Diagnosed with oesophageal manometry - elevated LES pressure
Treatment with endoscopic botulinum injection, dilatation or myotomy
Diffuse oesophageal spasm is a motility disorder with simultaneous uncoordinated oesophageal contractions
Symptoms of severe chest pain and dysphagia
Worse with acid reflux, hot or cold food
Treatment with calcium antagonists
Systemic sclerosis causes low amplitude oesophageal contractions and acid reflux, delayed gastric emptying leading to recurrent vomiting.
Patient are also at risk of SIBO causing chronic diarrhoea and malabsorption
Eosinophilic oesophagitis related to atopy and food allergy
Radiation oesophagitis follows radiotherapy to the trunk, causing fibrosis and stricturing
Extrinsic compression by can cause dysphagia
1. Mitral stenosis - enlarged left atrial
2. Thoracic aortic aneurysm
3. Mediastinal lymphadenopathy
Definitive investigations of Plummer-Vinson syndrome
- FBC - iron deficiency anaemia
- Iron studies
- Peripheral blood film (PBF)
- Barium swallow and video fluoroscopy
- Oesophago-gastroduodenoscopy (OGD) - oesophageal web
