Chronic dysphagia

Question 1

a 38-year-old woman presents with a six-month history of dysphagia. The dysphagia is worse with liquids compared with solid food. What are the differential diagnoses, investigations and management?

Answer 1

Impression
Chronic dysphagia given long-term difficulty swallowing solids. Given worse with liquids, this is suggestive of a functional cause rather than obstructive cause. Differentials split into functional and structural causes:
Functional
- Achalasia
- Scleroderma
- Oesophageal motility disorder
- Stroke
Structural
- strictures, webs, oesophageal rings
- masses (oesophageal carcinoma, lung mass)

Question 2

Chronic dysphagia - History

Answer 2

History

• sx: Nature of dysphagia (higher vs lower), frequency/severity, onset, pain, swallow saliva/drooling?
• REDF: fevers, weight loss, night sweats
• PMHx: GORD, autoimmune disease
• SNAP - smoking and alcohol

Question 3

Chronic dysphagia - Examination

Answer 3

Examination

• general appearance + vital signs
• examination of oral cavity
• neuro examination (signs of stroke)
• systemic exam for signs of scleroderma (CREST)
• calcinosis (cutaneous skin lesions)
• reynauds
• eosophagitis
• sclerodactyly’s
• telangiectasia’s

Question 4

Chronic dysphagia - Investigations

Answer 4

Investigations
- Key/diagnostic: upper endoscopy +/- biopsy (if indicated), or oesophageal manometry, barium swallow

• Bedside: vitals, assess airway
• Bloods: CRP/ESR, ANA/ENA (scl70 and other specific),
• Imaging: as above

Question 5

Chronic dysphagia - Management

Answer 5

Management
- depends on underlying aetiology.

Supportive:

• correct fluid, electrolyte and nutritional deficits secondary to chronic dysphagia
• dietary modifications (increased viscosity of fluids)
• speech path assessment, keep NBM in meantime (risk of aspiration)

Definitive
- consults: rheum for scleroderma, onc MDT for malignancy, neuro for other functional causes

• Scleroderma: immunotherapy
• Achalasia: pneumatic dilation, surgical myotomy, botox injection
• malignancy: MDT cancer involvement, patient specific treatment strategy