Dysphagia

Question 1

Important Hx questions for presenting complaint in dysphagia

Answer 1

Onset:
How did it start?
Time:
When did it start
Has it changed over time? Got worse or better?
Frequency:
Is it intermittent or do you always have trouble when eating/drinking?
Character:
Solids or liquids?
Site:
Where does the food/liquid feel like it is getting stuck?
Do you have trouble initiating a swallow? →oropharyngeal cause
Do you need tu turn your head or change position to swallow? →oropharyngeal
Alleviating/ exacerbating factors

Previous episodes like that?

Associated:
Do you choke or cough after you swallow?
Does food ever come back up your nose?
Weight loss
Heartburn
Acidic taste in the mouth when you wake up?

INFECTION: Pain, recent infections, fever

Question 2

PMHx pointing to a cause for dysphagia

Answer 2

PMHx
	GORD
	Thyroid
	Stroke
	ENT = problems with throat, surgeries
	Heart problems - mitral stenosis
	Neuro

Question 3

DHx

Answer 3

ALLERGIES

Pill-oesophagitis (corrosive to the oesophagus): doxycycline, iron sulphate, bisphosphonates, NSAIDS

Question 4

SHx in dysphagia?

Answer 4

How have things been in your life generally over recent months? Do you have any particular stresses or worries in your life at the moment? (somatisation)

Question 5

Types of dysphagia

Answer 5

oropharyngeal

oesophageal

Question 6

ddx for oropharyngeal

Answer 6

Stroke is the most common
Pharyngitis 
Oesophageal candidiasis 
Oropharyngeal carcinoma		
Thyromegaly (goitre) 
Cervical lymphadenopathy

	NEURO	
		§ Parkinson's disease 
		§ Multiple sclerosis 
		§ Myasthenia gravis 
		§ Sjogren's syndrome  (dry mouth+eyes)

Question 7

oesophageal dysphagia DDx

Answer 7

Peptic stricture
Oesophageal carcinoma - squamous cell ca, assoc w/ smoking, alcohol, reflux
Achalasia - loss of peristalsis in distal oesophagus, failure of lower sphincter relaxation. Both solids and liquids. Tx botulinum, endo or surgical dilatation
Diffuse oesophageal spasm → +intermittent chest pains MAY BE TRIGGERED BY HOT/COLD FOOD, relieved by GTN CCB
Systemic sclerosis → +/- delayed gastric emptying →vomiting
Scleroderma —- Raynaud’s Hx
Wilson’s
Eosinophilic Oesophagitis → assoc with atopy and food allergies
Radiation injury → Fibrosis and stricturing
Extrinsic comporession
LA enlargement in MS
Thoracic aorta aneurysm
Mediastinal Lymphnodes
Thyroid
Oesophageal infection
Immunosuppressants
HIV
Steroids
Pill induced (bisphosphonates, doxycycline)
Hiatal hernia

Question 8

Features of oropharyngeal dysphagia

Answer 8

Difficulty initiating swallowing
Associated nasal regurgitation
Assocaited coughinh, choking
Worse with LIQUIDS than solids
Hx of aspiration pneumonia
Hx of neurological disease, stroke
Associated with neuro Sx: dysarthria, weakness

Question 9

Feartures of oesophageal dysphagia

Answer 9

No difficulty in initiation but food stick soon after swallowing
Worse with SOLIDS
May be associated with reflux and dyspepsia
May be progressive
May be associated with ALARM Symptoms

Question 10

Hearburn - acid reflux predisposes to…

Answer 10

oesophagitis, oesophageal strictures, oesophageal adenocarcinoma

Question 11

Older age, male sex, heartburn or weight loss suggests…

Answer 11

mechanical (obstructive) cause.

Question 12

Rapid progression suggests…

Answer 12

malignancy

Question 13

Intermittent, non-progressive symptoms suggest

Answer 13

oesophageal web or ring