Chronic dysphagia

Question 1

A 38 year old woman presents with a 6 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
This woman has chronic dysphagia given the 6 month history of difficulty swallowing liquids. Given the greater difficulty swallowing liquids over solids, this clinically would be more congruent with a functional cause of dysphagia. Main complications of concern are any nutritional deficits/elecrtolyte derangements, and acute risk of aspiration pneumonia.

Broad differentials list should be considered. Causes of dysphagia can be categorised into structural and functional causes:

Structural:

• oesophageal webs, rings, strictures
• oesophageal mass: carcinoma, hyperplasia
• other head/neck neoplasia
• Crohns disease`

Functional

• scleroderma
• achalasia
• Primary oesophageal motility disorder
• stroke

Goals

• Thorough assessment with Hx/Ex, and further investigation using modalities such as oesophageal manometry, barium swallow and upper endoscopy +/- biopsy
• initiate appropriate short term mx to mitigate risks of aspiration, and long-term for optimising functionality with involvement of allied health

Question 2

Chronic dysphagia - History

Answer 2

History

• sx: difficulty swallowing, whereabouts can you feel it? solids? liquids? both? Progressive or stayed the same? gradual or sudden onset, globus sensation?
• screen for stroke symptoms/deficits (dysarthria, dysphonia, etc), screen for resp obstruction
• CVD risk factors for stroke, ask about autoimmune disease, run in family? sx of scleroderma (bird facies, sclerodactyly, calcinosis, reynauds, oesophageal dysmotility, telangiectasia)
• PMHx, SNAP

Question 3

Chronic dysphagia - Examination

Answer 3

Examination

• General appearance + vital signs (cachexia, discomfort, etc)
• neuro exam: cranial nerves, focal neurology
• systems review (malignancy

Question 4

Chronic dysphagia - Investigations

Answer 4

Investigations
Key/diagnostic
- upper endoscopy: observe abnormality, biopsy of neoplasia, potentially therapeutic in setting of structures
- Barium swallow: beak like narrowing (achalasia)
- oesophageal manometry: distinguish different motility disorders (scleroderma)

Other

• bedside: swallow assessment (speech path)
• bloods: FBC, UEC (electrolyte derangements), LFT, ANA/ENA + Scl70 ABs, CRP/ESR, B12/folate, vitamin panel, iron studies (anaemia)
• imaging: consider CXR, CT chest, but otherwise as above

Question 5

Chronic dysphagia - Management

Answer 5

Management
Specific definitive management will depend on the underlying aetiology.
- involvement of gen surg early in presentation

Supportive

• Fluids, electrolyte derangement reversal
• Nutritional support, supplements, TPN if truly no ability to swallow
• swallow assessment, NBM if aspiration risk
• OT referral, Physio for

Definitive
- Scleroderma: rheumatology referral, corticosteroids, gastroenterology referral. Likely PPIs, and other non-pharmacological treatments (positioning, small meals, thickened fluids, etc). Severe reflux may require anti-reflux surgeries (e.g. cardiomyotomy)

• Achalasia: pharmacological treatment with smooth muscle relaxants such as nitrates, CCBs. otherwise can have pneumatic dilation, and other laparoscopic procedures.
• neoplasia: MDT