Dysphagia Flashcards
What is dysphagia?
difficulty swallowing
Where is high dysphagia and when does food get stuck?
- oropharyngeal and upper oesophageal
2. difficulty in initiating swallow or immediately upon swallowing
Where is low dysphagia and when does food get stuck?
- lower oesophageal
2. feels the food gets stuck a few seconds after swallowing
What is odynophagia?
painful swallowing
When can you get odynophagia?
- Malignancy
2. Candidiasis
What is globus?
common sensation of having lump in throat without true dysphagia
What are the functional causes of high dysphagia?
- Stroke
- Parkinson’s disease
- Myasthenia gravis
- MS
- Myotonic dystrophy
- Inadequate saliva production
What are the functional causes of low dysphagia?
- Achalasia
- Chagas disease
- Nutcracker oesophagus
- Diffuse oesophagial spasm
- Limited cutaneous scleroderma (CREST)
- Infective oesophagitis
- Eosinophilic oesopahgitis
What are the luminal (structural) causes of low dysphagia?
foreign body
What are the mural (structural) causes of high dysphagia?
- Cancer
- Pharyngeal Pouch
- Cricopharyngeal bar
What are the mural (structural) causes of low dysphagia?
- Cancer
- Stricture (caustic or inflammatory)
- Pulmmer-Vinson syndrome
- Schatzki ring
- Congenital atresia
- Post-fundoplication
What are the extrinsic (structural) causes of low dysphagia?
- Mediastinal mass
- Retrosternal goitre
- Bronchial carcinoma
- Thoracic aortic aneurysm
- Pericardial effusion
- Ortner’s syndrome
- Dysphagia Lusoria
What must you think new onset dysphagia in middle-aged to elderly patients?
carcinoma until proven otherwise
What questions fo you need to ask a patient with dysphagia related to swallowing?
- Duration of symptoms
- Is the dysphagia progressive or intermittent?
- Is the dysphagia to solids, fluids or both?
What would present immediately during a meal?
food bolus stuck in oesophagus
What does dysphagia of a short history of days to week suggest?
cancer
What does dysphagia lasting months to years suggest
chronic motility disorders e.g. achalasia
What would progressive dysphagia suggest?
stricture (benign or malignant)
What would intermittent dysphagia suggest?
motility disorder
If the patient is able to swallow fluid as normal but has difficulty with solid food (sticking) what does this suggest?
mechanical obstruction e.g. stricture
If dysphagia initially more pronounced for fluids than solids what would it suggest?
motility disorder e.g. achalasia or neuromuscular condition
What would absolute dysphagia to to solids, liquids, saliva suggest?
- food bolus stuck due to malignancy or stricture
- poorly chewed
What associated questions do you ask about in dysphagia?
- Any coughing and if so related to eating
- Suffer from halitosis
- Any gurgling or dysphonia
- Heartburn or water brash
- Weight loss
- Neurological symptoms
- Rheumatological symptoms
What would choking (coughing straight after swallowing) suggest?
coordination issue: stroke + Parkinsons
What would coughing some time after food suggest?
regurgiation of food in
- pharyngeal pouch
- achalasia
- GORD
What would nocturnal cough suggest?
achalasia
What would suffering from halitosis suggest?
food remains lodged in oropharynx e.g. Pharyngeal Pouch
What would gurgling soon after eat or drink / visible bulge in neck suggest?
pharyngeal pouch
what would hoarseness suggest?
vocal cord dysfunction due to tumour affected reccurent laryngeal nerve
What would heartburn and waterbrash suggest?
reflux disease with or without strictrue
What can chronic dyspepsia predispose to?
oesophageal cancer
What do 40% of people with achalasia complain of?
retrosternal burning
What do 40% of people with achalasia complain of?
retrosternal burning
Why do you ask about weight loss with dysphagia?
red flag for oesophageal cancer
When do you ask about neurological symptoms with dysphagia?
symptoms of functional dysphagia
What are functional dysphagia symptoms to look for?
- difficulty swallowing
- slow eating
- extra effort required to eat/chew
- tiredness after eating
- early dysphagia for liquids
When do you enquire about rheumatological symptoms in dysphagia?
limited cutanous scleroderma (CREST)
What PMHx is important to check for in dysphagia?
- Gord
- Peptic Ulcers
- MS or Parkinsons
What does gord predispose to?
- oesophageal adenocarcinoma
- non-malignant strictures of oesophagus
Why should you check if patient has had fundoplication for GORD?
post-operative dysphagia complication
Why do you ask about peptic ulcers with dysphagia?
can lead to scarring and strictures around gastric cardia and lower oesophagus
What do you check if patient has no firm diagnosis of GORD or peptic ulcer but you suspect?
may complain of dyspepsia and/or waterbrash
What DHx is important to check in dysphagia?
- CCB and nitrates
2. NSAIDs, aspirin, steroids and bisphosphonate
Why do you check CCBs and nitrates?
can exacerbate reflux symptoms by decreasing oesophageal tone
Why do you check about NSAIDs, aspirin, steroids and bisphosphonates?
predispose to peptic ulceration
What are the five important examinations for a patient with dysphagia?
- Cranial nerve pathology
- Signs of GI malignancy
- Neck Mass
- Features of CREST
- Koilonychia
Why do you examine cranial nerve pathology?
important if history suggests functional dysphagia e.g. patient may have bulbar palsy
What could suggest oesophageal cancer on examination?
- cachetic
- palpable Virchow’s node
When could a GI malignancy be palpable?
- If extends to cardia of stomach may be palpable in thin patients
- Can metastasise to liver to check for hepatomegaly
What can you palpate in the neck with dysphagia?
- large pharyngeal pouch in thin patients (may gurgle on palpatation)
- Goitre
What can head and neck cancers cause?
-cervical lymphadenopathy -upper (oropharyngeal) dysphagia
What are the features of CREST syndrome?
- Calcinosis
- Raynauds
- Oesophageal dysmotlity
- Sclerodactyly
- Telangiectasia
What does koilonychia suggest and what is it associated with dysphagia?
- severe iron deficiency anaemia
2. assoicated with Plummer-vinson syndrome
What are the investigations for dysphagia?
- Barium swallow
- Endoscopy
- Videofluroscopy
- Monometery
What is barium swallow? What is sometimes given?
- Cineradiographic study in supine patient from upper to lower oesophageal sphincter
- sometimes effervesent agent to produce double contrast study that is better at seeing mucosal lesions
When is barium swallow useful?
high lesion (as can’t do endoscopy and if pharyngeal pouch or oesophgeal cancer risk perforation)
When is barium swallow indicated?
achalasia
What does endoscopy allow visulisation of?
luminal and mural lesion
What can you do during endoscopy?
- can biopsy
- treat lesions
- carry out procedures
Why is endoscopy better than barium swallow?
more sensitive and specific than double contrast barium swallow
When is endoscopy the first line investigation?
low dysphagia
What is videofluroscopy?
modified barium swallow as barium in liquid form and speech therapist runs
When is videofluroscopy suitable?
functional high dysphagia
What does manometry do?
assess pressure in lower oesophageal sphincter and peristaltic wave in the rest of oesphagus
What is manometry used to diagnose?
motility disorder and distinguishing which one
When is manometry indicated?
when barium swallow and/or endoscopy are unremarkable suggesting a cause other than mechanical obstruction
What would a velvety epithelium in distal oesphagus suggest?
Barrett’s oesophagus
What tests do you do for staging of adenocarcinoma?
- Spiral CT Chest/abdomen
- PET scan
- Endoscopic US (no evidence of metastatic disease on CT/PET)
- Laparoscopy (no evidence of metastatic disease on CT/PET)
What happens if the tumour is suitable for radical treatment?
aneasthatist perform fit assesment test
What is prognosis of oesophageal cancer like?
- Prognosis depends on stage
- Stage 1 - 5year survival 80%
- 70% of patients present with lymph node involvement where 5 year survival 15%
