Dysphagia Flashcards
Dysphagia definition
difficulty in swallowing
Causes of dysphagia
- Oropharyngeal
- oesophageal
- Mechanical
- Motility
- neuromuscual
- congenital
Oral causes
- Congenital – cleft palate
- Inflammatory- stomatitis, glossitis, TMJ arthtis, trismus, dental abscess
- Trauma – maxilla
- Neurological – palsyw
- Neoplastic- salivary tumours
Pharyngeal causes
- Pharyngeal diverticulum – congenital
- Inflammatory- pharyngitis, quinsy, abscess
- Trauma: corrosive positiong
- Neurological – tetanus
- Neoplastic
Oesophageal mechancal causes
Mechanical
In the lumen
- Food bolus
- Foreign body
- Oesphageal web (eg scleroderma)
- Plummer-vinson syndrome
In the wall
- Inflammatory stricture (GORD, Causitic stricture)
- Candidiasis
- Carcinoma
- Post radiation
- Scleroderma
- Plummer-vinson syndrome
- Chagas disease
- Oesophagitis
- Barrets oesophagus
Outside the wall
- Retrosternal Goiter
- Paraoedophageal hiatus hernia
- Mediastinal tumours
- Bronchial carcinoma
- Lymphadenopathy
- Pharyngeal pouch
- Enlarge left atrium
- Thoracic aortic aneurysm
oesophageal Motility disorders
- Diffuse oesophageal spasm
- Achalasia
Oesophageal Neuromuscular disorders
- CVA
- Bulbar palsy
- Guillan-barre syndrome
Congenital oesophageal causes
Oesophageal atresia- associated with maternal polyhydramnios. Newborn will show dribbling, inability to swallow feeds, production of frothy musucs, chocking and cyantoic attacks and chest infections
5 questions to ask with dysphagia
- Was there difficult swallowing solids and liquids from the start
- yes – motility disorder (esp if non progressive- achalasia, cns or pharyngeal causes),
- no- solids then liquids suspect a stricture (benign or malignant)
- Is it difficult to make the swallowing movement
- Yes – bublar palsy, especially if the patient coughs on swallowing
- Is it painful –odynophagia?
- Yes – suspect cancer, oesophageal ulcer (benig or malignant), candida (immunocompromised or poor steroid inhaler) or spasms
- Is the dysphagia intermittent or is it constant and getting worse?
- Intermittent- oesophageal spasm
- Constant and worsening – suspect malignant stricture
- Does the neck bulge r gurgle on drinking?
- Yes – suspect a pharyngeal pouch
How to localise the anatomical location of the problem ?
How to differentiate structural or dysmotility oesophageal cause of dysphagia?
Progressive dysphagia
Neuromuscular
DIfficulty initiating swallowing
Oropharyngeal dysphagia
Food sticks after swallowing
oesophageal dysphagia
Associated with cough
early - neuromuscular
late- obstructive
Weight loss in elderly
carcinoma `
Weight loss with regurgitation
achlasia
Progressive dysphagia with heartburn
Peptic stricure, GORD
Pain with dysphagia
Oesophagitis
Pain made worse by
- solids only
- solids and liquids
- solids - obstructive
- solids and liquids - neuromuscular dysphagia
Dysphagia examination
- Is the patient cachetic or anaemic
- Examine the mouth
- Feel for supraclavicular lymph nodes (left supraclavicular node = virchows node- intra-abdominal mass)
- Look for signs of systemic disease e.g
- systemic sclerosis (calcinosis, raynayds, sclerodactyl and telangiectasia)
- Enlarged left atrium – mitral stenosis e.g peripheral cyanosis, malar flush, left parasternal heave
- Koiloncychia, angular stomatitis and glossitis – plummer vinson syndrome
- Carcinoma – weight loss, palpable liver, cervival lymphadenopathy
- Pharyngeal pouch – palpable swelling in the posterior triangle of the neck
Invrstigations for dysphagia
- FBC, ESR
- Hb descreased associated with carcinoma but also occurs with oesophagitis
- Anaemia – plummer-vinson syndrome
- ESR increased in malignancy and scleroderma
- U and Es
- Dehydration
- LFTs
- Alkaline phosphatase increased in liver secondaries
- CXR
- Foreign body if radio-opaque
- Air-fluid level in achalasia
- Gastric air bubble – paraoesapheal hernia
- Bronchial carcinoma
- Widened mediastinum – aortic aneurysm
- Large left atrium (double shadow behind heart)
- Specific investigations
- Barium swallow – 1st line investigation pharyngeal pouch (never OGD as it may perforate the pouch), stricture, achalasia, external compression
- OGD (oesophageal-gastro dudeonscopy) – food bolus, candidiasis, benign versus malignant stricture, oesophageal web, best assessment of oesophageal mucosa, masses can be identified and biopsied
- CT – if thinking extrinsic compression (goiter, mediastinal nodes, spread of malignancy, tumour staging, aortic aneurysm)
- Manometry – manometry is used to assess co-ordination and strength of peristaltic movement in the oesophagus and also the sphincter process
Logistical approach to managing dysphagia
