Dysphagia

Question 1

Name most common causes of dysphagia?

Answer 1

Oesophageal caner
Oesophagitis
Oesophageal candidiasis
Achalasia
Pharyngeal pouch
Systemic sclerosis
Myasthenia gravis
Globus hystericus

Question 2

Useful to think about causes of a symptoms in a structured way including:

Answer 2

Extrinsic
- mediastinal masses
- cervical spondylosis

Oesophageal wall
- achalasia
- diffuse oesophageal spasm
- hypertensive lower oesophageal sphincter

Intrinsic
- Tumours
- Strictures
- Oesophageal web
- Schatzki rings

Neurological
- CVA
- Parkinson’s disease
- MS
- Brainstem pathology
- Myasthenia gravis

Question 3

Investigations for dysphagia?

Answer 3

• All patients require an upper GI endoscopy unless there are compelling reasons for this not to be performed. Motility disorders may be best appreciated by undertaking fluoroscopic swallowing studies.
• A full blood count should be performed.
• Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.

Question 4

Cause of dysphagia?? A 55-year-old man presents with a history of progressive dysphagia over the past 4 weeks. For the preceding 5 years he had regularly attended his general practitioner with symptoms of dyspepsia and reflux.

Answer 4

Carcinoma of the oesophagus → A short history of progressive dysphagia in a middle aged man who has a background history of reflux is strongly suggestive of malignancy. Long standing reflux symptoms may be suggestive of a increased risk of developing Barretts oesophagus. Note that not all patients with Barretts transformation alone are symptomatic.

Question 5

Cause of dysphagia?? A 40-year-old man presents with symptoms of dysphagia that have been present for many months. His investigations demonstrate lack of relaxation of the lower oesophageal sphincter during swallowing.

Answer 5

Achalasia → Patients with dysphagia will usually undergo an upper GI endoscopy as a first line investigation. Where this investigation is normal, the next stage is to perform studies assessing oesophageal motility. These comprise fluroscopic barium swallows and oesophageal manometry and pH studies. Lack of sphincter relaxation suggests achalasia (pressures are usually high).

Question 6

Cause of dysphagia ?? A 4-year-old presents with sudden onset of dysphagia. He undergoes an upper GI endoscopy and a large bolus of food is identified in the mid oesophagus. He has no significant history, other than a tracheo-oesophageal fistula repair soon after birth.

Answer 6

Benign oesophageal stricture → Children with tracheo-oesophageal fistulas will commonly develop oesophageal strictures following repair. These may require regular dilations throughout childhood.

Question 7

Pharyngeal pouch?

Answer 7

More common in older men

Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles

Usually not seen but if large then a midline lump in the neck that gurgles on palpation

Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen

Question 8

Oesophageal candidiasis?

Answer 8

There may be a history of HIV or other risk factors such as steroid inhaler use

Question 9

Systemic sclerosis?

Answer 9

Other features of CREST syndrome may be present, namely Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia

As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased. This contrasts to achalasia where the LES pressure is increased