Dysphagia Flashcards
Doug Caldwell, 54 year old man with a long Hx of heartburn who presents to his local doctor, Dr Simon Wood, with a 3/12 Hx of progressive dysphagia
First noticed his swallowing problem 3/12 ago when he found that if he did not cut meat ino small portions and chew it well, it seemed to stick in his chest; able to deal with this by being careful with meat, but gradually problem seems to be getting worse and he has had to modify his meals to soften food
Sister now makes him soups, mashed vegetables and minces his meat; swallowing liquids has never been a problem
No N + V but was in pain one day when a piece of carrot “got stuck” for ages and eventually went down; has been careful since then
What pattern of dysphagia is Mr Caldwell describing?
What sort of causes are you thinking of?
Mechanical
Causes: obstructive (extramural, mural, intraluminal)
Doug Caldwell, 54 year old man with a long Hx of heartburn who presents to his local doctor, Dr Simon Wood, with a 3/12 Hx of progressive dysphagia
Says he feels healthy and has no complaints about general health; coughs a bit and has bronchitis in winter but thinks this is because he smokes
PHx: heartburn (for years, never treated)
FHx: sister with hiastus hernia (he uses her Mylanta and Gaviscon which usually help; if his heartburn is really bothering him he takes some of her Zantac or Somac tablets for a few days)
What is heartburn?
What is the likely cause of Mr Caldwell’s heartburn?
What is the evidence for this?
How might the heartburn link to his complaint of dysphagia?
“Heartburn” as described by patients is usually a retrosternal burning sensation caused by reflux of stomach acid into the oesophagus; however it is important to clarify what the patients mean as the term is non-specific
The likely cause of Mr Caldwell’s heartburn is GORD (possibly complicated by a hiatus hernia)
The evidence for this include his risk factors (smoking, FHx)
If Mr Caldwell has GORD, this may have caused a stricture or prediposed to adenocarcinoma of the distal oesophagus secondary to dysplastic transformation; this could be the cause of his dysphagia (hiatus hernia may also uncommonly cause dysphagia)
Mr Caldwell, 54 year old male, presents with progressive dysphagia
Smoker of 20 cigarettes/day for 40 years, 2 stubbies of full strength beer/day for 30 years
FHx: lung cancer (older brother)
Social: on unemployment benefit for 3 years since closure of shirt factory in which he worked
Does this information help you to refine your hypothesis?
What factors will you look for O/E with regard to his dysphagia and your hypothesis as to its cause?
Smoking Hx and FHx of lung cancer may increase the likelihood of oesophageal or thoracic tumour causing extrinsic compression
O/E: vitals, look for lymphadenopathy, respiratory and CV examination
Special tests for oesophageal dysphagia?
Barium swallow
Upper GI endoscopy
Stricture Mx?
Endoscopic oesophageal dilation
4 motility disorders causing oesophageal dysphagia
Achalasia
Diffuse oesophageal spasm
Systemic sclerosis
Oesinophilic oesophagitis
5 causes of mechanical obstruction which may result in oesophageal dysphagia
Peptic stricture
Oesophageal cancer
Lower oesophageal rings/webs
Extrinsic compression by mediastinal masses (e.g. enlarged LA, aortic aneurysm, aberrant subclavian artery - termed dysphagia lusoria, substernal thyroid, cervical bony exostosis, thoracic tumour including lymphoma)
Caustic ingestion
6 neurologic disorders which may cause oropharyngeal dysphagia
Stroke
PD
MS
Some motor neuron disorders (amyotrophic lateral sclerosis, progressive bulbar palsy, pseudobulbar palsy)
Bulbar poliomyelitis
GCA
4 muscular causes of oropharyngeal dysphagia
Myasthenia gravis
Dermatomyositis
Muscular dystrophy
Cricopharyngeal incoordination
