Dysphagia

Question 1

Dysphagia definition

Answer 1

difficulty in swallowing

Question 2

Causes of dysphagia

Answer 2

• Oropharyngeal
• oesophageal
  
  • Mechanical
  • Motility
  • neuromuscual
  • congenital

Question 3

Oral causes

Answer 3

• Congenital – cleft palate
• Inflammatory- stomatitis, glossitis, TMJ arthtis, trismus, dental abscess
• Trauma – maxilla
• Neurological – palsyw
• Neoplastic- salivary tumours

Question 4

Pharyngeal causes

Answer 4

• Pharyngeal diverticulum – congenital
• Inflammatory- pharyngitis, quinsy, abscess
• Trauma: corrosive positiong
• Neurological – tetanus
• Neoplastic

Question 5

Oesophageal mechancal causes

Answer 5

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

Question 6

oesophageal Motility disorders

Answer 6

• Diffuse oesophageal spasm
• Achalasia

Question 7

Oesophageal Neuromuscular disorders

Answer 7

• CVA
• Bulbar palsy
• Guillan-barre syndrome

Question 8

Congenital oesophageal causes

Answer 8

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

Question 9

5 questions to ask with dysphagia

Answer 9

1. Was there difficult swallowing solids and liquids from the start
   
   1. yes – motility disorder (esp if non progressive- achalasia, cns or pharyngeal causes),
   2. no- solids then liquids suspect a stricture (benign or malignant)
2. Is it difficult to make the swallowing movement
   
   1. Yes – bublar palsy, especially if the patient coughs on swallowing
3. Is it painful –odynophagia?
   
   1. Yes – suspect cancer, oesophageal ulcer (benig or malignant), candida (immunocompromised or poor steroid inhaler) or spasms
4. Is the dysphagia intermittent or is it constant and getting worse?
   
   1. Intermittent- oesophageal spasm
   2. Constant and worsening – suspect malignant stricture
5. Does the neck bulge r gurgle on drinking?
   
   1. Yes – suspect a pharyngeal pouch

Question 10

How to localise the anatomical location of the problem ?

Answer 10

Question 11

How to differentiate structural or dysmotility oesophageal cause of dysphagia?

Answer 11

Question 12

Progressive dysphagia

Answer 12

Neuromuscular

Question 13

DIfficulty initiating swallowing

Answer 13

Oropharyngeal dysphagia

Question 14

Food sticks after swallowing

Answer 14

oesophageal dysphagia

Question 15

Associated with cough

Answer 15

early - neuromuscular

late- obstructive

Question 16

Weight loss in elderly

Answer 16

carcinoma `

Question 17

Weight loss with regurgitation

Answer 17

achlasia

Question 18

Progressive dysphagia with heartburn

Answer 18

Peptic stricure, GORD

Question 19

Pain with dysphagia

Answer 19

Oesophagitis

Question 20

Pain made worse by

• solids only
• solids and liquids

Answer 20

• solids - obstructive
• solids and liquids - neuromuscular dysphagia

Question 21

Dysphagia examination

Answer 21

• 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

Question 22

Invrstigations for dysphagia

Answer 22

• 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 – 1^st 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

Question 23

Logistical approach to managing dysphagia

Answer 23