Dysphagia

Question 1

What is dysphagia?

Answer 1

Dysphagia refers to difficulty in swallowing.

Question 2

What should dysphagia always be diagnosed as first?

Answer 2

Unless the history is very convincing otherwise, dysphagia is oesophageal cancer until proven otherwise, and most patients presenting with dysphagia need an urgent upper GI endoscopy.

Question 3

Give examples of mechanical causes of dysphagia

Answer 3

• Oesophageal or gastric malignancy
• Benign oesophageal strictures
• Extrinsic compression
• Pharyngeal pouch
• Foreign body (mainly in children)
• Oesophageal web

Question 4

Give examples of neuromuscular causes of dysphagia

Answer 4

• Post-stroke
• Achalasia
• Diffuse oesophageal spasm
• Myasthenia gravis
• Myotonic dystrophy

Question 5

What symptoms need to be asked about in the history of dysphagia?

Answer 5

In the assessment of dysphagia, clarify the exact nature of the symptoms, such as:

• Is there difficulty in initiating the swallowing action?
• Do you cough after swallowing?
• Do you have to swallow a few times to get the food to pass your throat?

Other symptoms to assess for include the presence of regurgitation, the sensation of food becoming ‘stuck’, a hoarse voice, weight loss, or any referred ear or neck pain.

Question 6

What investigations should be ordered for dysphagia?

Answer 6

All patients should be sent for an endoscopy ±biopsy to exclude any potential malignancy as a priority. Routine bloods, including FBC and LFTs, may also be required if malignancy is suspected.

If the endoscopy is normal and a motility disorder is suspected, manometry and 24hr pH studies will be required. If a pharyngeal pouch (or any other diverticulum) is suspected, barium swallow studies can be performed.

Question 7

Briefly describe the Cancer Referral Pathway for oesophageal cancer

Answer 7

In the UK, NICE recommends urgent upper GI endoscopy within 2 weeks to assess for oesophageal cancer in people:

• With dysphagia
• Aged ≥55yrs with weight loss plus
• Upper abdominal pain
• Reflux
• Dyspepsia

Non-urgent referral is recommended with haematemesis or ≥55yrs with treatment resistant dyspepsia or upper abdominal pain.

Question 8

Briefly describe the management of dysphagia

Answer 8

The mainstay of management in dysphagia is treatment of the underlying cause.

As a broad overview, treatment of malignancy is via surgical excision or palliation (with chemotherapy or stents), whereas motility disorders are treated by targeting the underlying cause and referral for swallowing therapy.

In cases where no immediate reversible cause is identified, referral to speech and language therapists and to dieticians is advisable.