Dysphagia

Question 1

What is dysphagia

Answer 1

Difficulty swallowing

Question 2

The causes of dysphagia can be split into:

Answer 2

Inflammatory
Mechanical
Motility disorders

Question 3

Inflammatory cause of dysphagia are:

Answer 3

Tonsilitis, pharyngitis
Oesophagitis: GORD, candida
Oral candidiasis
Aphthous ulcers

Question 4

Mechanical causes of dysphagia

Answer 4

Luminal: FB, large food bolus
Mural –> Benign stricture: Web, oesophagitis, trauma e.g. OGD
–> Malignant stricture: pharynx, oesophageal, gastric
–>Pharyngeal pouch
Extra-mural: Lung Ca, rolling hiatus hernia, mediastinal lymph nodes e.g. in lymphoma, retrosternal goitre, thoracic aortic aneurysm

Question 5

Motility disorder causes of dysphagia

Answer 5

Local: Achalasia, diffuse oesophageal spasm, nutcracker oesophagus, bulbar/pseudobulbar palsy (CVA/MND)
Systemic: systemic sclerosis/ CREST syndrome/ MG

Question 6

Presentation

Answer 6

If swallowing both liquids and food is difficult at start: motility disorder
If food> liquids –> stricture
Difficulty making swallowing movement = bulbar palsy
Odonophagia: Cancer, oesophageal ulcer, spasm
Intermittent: oesophageal spasm
Constant and worsening: malignant stricture
Neck bulges or gargles on drinking: pharyngeal pouch

Question 7

Signs associated with dysphagia

Answer 7

Cachexia
Anaemia 
Virchow's node (+ve = Troisier's sign)
Neurology 
Signs of systemic disease e.g. scleroderma

Question 8

Investigations for dysphagia

Answer 8

Bloods: FBC, U&E
CXR
OGD
Barium swallow +/- video fluoroscopy 
Oesophageal manometry

Question 9

What is achalasia?

Answer 9

Degeneration of the myenteric plexus (Auerbach’s) causing reduced peristalsis and LOS fails to relax

Question 10

What are the causes of achalasia

Answer 10

Primary = idiopathic = commonest 
Secondary = oesophageal Ca, Chaga's disease (T.cruzii)

Question 11

Presentation of achalasia

Answer 11

Dysphagia: liquids and solids at the same time
Regurgitations
Substernal cramps
Weight loss

Question 12

What is a complication of chronic achalasia

Answer 12

Chronic achalasia can progress to oesophageal SCC

Question 13

Investigations for achalasia

Answer 13

Barium swallow - dilated tapering oesophagus - birds beak)
Manometry - failure of relaxation and reduced peristalsis
CXR: may show widened mediastinum
OGD: exclude malignancy

Question 14

Management of achalasia

Answer 14

Medical: CCBs, nitrate
Int: endoscopic balloon dilatation, botulinum toxin injection
Surgical: Heller’s cardiomyotomy open or endo

Question 15

What is a pharyngeal pouch/ Zenker’s diverticulum

Answer 15

outpouching of oesophagus between upper border of cricopharyngeus muscle and lower border of inferior constrictor of pharynx
weak area called: Killian’s dehiscence

Question 16

Where does the pharyngeal pouch occur?

Answer 16

Defect usually occurs posteriorly but swelling usually bulges to the left side of the neck

Question 17

What is the presentation of pharyngeal pouch?

Answer 17

Regurgitation
Neck bulge
Halitosis
Gurgling sounds on drinking

Question 18

Pathology of pharyngeal pouch

Answer 18

Food debris –> pouch expansion –> oesophageal compression –> dysphagia

Question 19

Management of pharyngeal pouch

Answer 19

Excision

Endoscopic stapling

Question 20

What is diffuse oesophageal spasm?

Answer 20

Intermittent dysphagia +/- chest pain

Ba swallow shows corkscrew oesophagus

Question 21

What is nutcracker oesophagus?

Answer 21

Increased contraction pressure with normal peristalsis