Dysphagia Flashcards
What is globus?
The sensation of having a lump in the throat without true dysphagia
What the most common diagnosis of dysphagia?
High dysphagia - Generalised/systemic neuromuscular disease
Low dysphagia - Local obstructing lesion
What is the diagnosis that must be ruled out with new-onset dysphagia?
Carcinoma
What questions must be asked about dysphagia?
What is the duration of the symptoms?
Is it progressive or intermittent? (progressive suggests stricture whereas intermittent are more characteristic of motility disorders)
Is the dysphagia to solid, fluids or both?
Why is the time course of dysphagia important?
Cancer typically presents with a short history of days to weeks
Chronic motility disorders such as achalasia present with symptoms lasting months to years
What associated symptoms are important in dysphagia?
Coughing (stroke/Parkinson’s)
Choking (functional problem)
Gurgling/dysphonia (pharyngeal pouch)
Heartburn
Nocturnal cough/wheeze (achalasia)
Neuro/rheumatological symptoms
What is important in someones PMH with dysphagia? and why?
GORD - Predisposes to oesophageal adenocarcinoma and non-malignant strictures
Peptic ulcers - Scarring and strictures around the gastric cardia and lower oesophagus
How can drugs contribute to dysphagia?
Drugs that relax smooth muscles (eg calcium channel blockers and nitrates) can decrease oesophageal tone
Drugs such as NSAIDs can predispose peptic ulceration
What should be examined in a patient presenting with dysphagia?
Cranial nerves
Signs of GI malignancy (Virchow’s)
Neck masses
Features of CREST syndrome
Koilonychia (suggests severe iron-deficiency anaemia which can cause Plummer-Vinson syndrome)
What are the five features of CREST syndrome?
Calcinosis Raynauds Esophageal dysmotility Sclerodactyly Telangiectasia
What does a ‘velvety’ epithelium normally suggest when seen on ODG?
Barrett’s oesophagus
Miss Aggrawal is a 27-year-old lawyer who presents with a 2-year history of mild dysphagia to both solids and liquids. She says that she has no problems with coordinating swallowing in her mouth, but feels that food and drink are sticking on their way down to her stomach. She has not noticed any choking or gurgling related to eating and is not aware of any weight loss. She has visited her GP twice in the last year, complaining of heartburn and a nocturnal cough. These were attributed to GORD and asthma, respectively, despite no assessment of her peak flow, and she
was offered acid-suppressing medication and a bronchodilator inhaler. Neither of these therapies has eased her symptoms, however. She takes no other medications and is otherwise f t and well.
Given Miss Aggrawal’s dysphagia to liquids, her GP performs a thorough examination of her peripheral nervous system and cranial nerves, but nothing abnormal is noted. Abdominal and neck examinations are also unremarkable.
The GP refers Miss Aggrawal for a barium swallow. This shows a dilated oesophagus with a beak-like terminal narrowing. Manometry is also performed and shows an elevated lower oesophageal sphincter
pressure with incomplete relaxation of the sphincter and aperistalsis in the body of the oesophagus.
Achalasia
What are the treatments options for achalasia?
Pneumatic balloon dilatation
Surgical myotomy
Botox injections
Drugs
Mr Giles is a 60-year-old farmer who is brought to hospital by ambulance. He was at a local cattle market when he developed chest pain and his fellow farmers called an ambulance. He was given glyceryl trinitrate (GTN) en route to hospital, which relieved his pain, and an early ECG revealed no signs of ischaemia. On arrival at A&E he is pain free and repeat ECGs are unremarkable. He describes how he has had intermittent central crushing chest pain for the last year. He has been hospitalized twice with the pain, and had an angiogram during his last admission which revealed patent coronary arteries. On further questioning
he describes getting episodes of chest pain at least once a week, but that they are responsive to GTN. The pain does not radiate, and it is not induced by exercise.
A functional enquiry reveals that Mr Giles has been troubled by heartburn for ‘some years’ and takes antacid tablets whenever he feels the need. When specifically asked whether his chest pain ever coincides with a difficulty swallowing food he says ‘yes’.
Mr Giles’s past medical history is significant for hypertension, for which he takes bendroflumethiazide
and ramipril. He is a cigarette smoker with a 12-pack-year history (20 cigarettes a day for 12 years), and enjoys about 10 pints of ale a week.
The A&E registrar examines Mr Giles but does not find anything remarkable. He requests a blood troponin, which is negative, and discharges Mr Giles with a diagnosis of ‘non-cardiac chest pain’.
Oesophageal spasm
Mr Gan is a 64-year-old retired restaurateur who presents to his GP with a 5-week history of progressive dysphagia to solids. He describes how it feels as if food items are getting stuck halfway down his throat.
He denies any choking, gurgling, heartburn, or waterbrash. He has, however, suffered from increasing dyspnoea over the past 2 months, and has been coughing for a couple of weeks. The coughing occurs both day and night, and has recently been associated with episodes of haemoptysis. Mr Gan thinks that he has lost about 4 kilos in the past couple of months and describes feeling increasingly lethargic.
He has no significant past medical history and takes no regular medications. He does not drink, but has a 40-pack-year history of cigarette smoking.
On examination, Mr Gan is cachectic. There is hepatomegaly and palpable lymph nodes in his left supraclavicular fossa. Percussion and auscultation of Mr Gan’s chest is unremarkable, as is a neurological exam.
Extrinsic compression
