Dysphagia Flashcards
Define dysphagia.
Difficulty swallowing
What is the difference between low dysphagia and high dysphagia?
High Dysphagia – patients tend to have problems with initiating the swallow or immediately upon swallowing
Low Dysphagia – patients feel that food gets stuck a few seconds after swallowing
What is odynophagia?
Painful swallowing
Broadly speaking, what are the two main causes of odynophagia?
Malignancy
Infection (more common)
What is globus?
Common sensation of having a lump in one’s throat without true dysphagia
This is a benign condition
Other than anatomically, how else is dysphagia classified?
Functional
Structural
List some differentials for high dysphagia:
- Functional Stroke Parkinson’s Disease Multiple Sclerosis Myotonic Dystrophy Motor Neurone Disease Myasthenia Gravis - Structural Cancer Pharyngeal Pouch Cricopharyngeal Bar
List some differentials for low dysphagia:
- Functional Achalasia Chagas Disease Nutcracker Oesophagus Limited Cutaneous Systemic Sclerosis Diffuse Oesophageal Spasm Infective and Eosinophilic Oesophagis - Structural Cancer Stricture Foreign Body Plummer-Vinson Syndrome Post-Fundoplication Mediastinal Mass Retrosternal Goitre Bronchial Carcinoma
List some important questions to ask about the history of presenting complaint.
How long has the dysphagia been around for?
Has the dysphagia been progressive or persistent?
Has the dysphagia been accompanied by a cough?
Has there been any gurgling or dysphonia?
Is the dysphagia to solid, liquids or both?
Has there been any halitosis?
Has there been any heartburn or waterbrash?
Has there been any unintentional weight loss?
Have there been any neurological symptoms?
Have there been any rheumatological symptoms?
Describe the duration of symptoms that is typically associated with oesophageal cancer.
Cancer is usually associated with a relatively short history (days/weeks) because the cancer will reach a size at which symptoms begin to appear rapidly
What are the likely causes of chronic dysphagia lasting months/years?
Motility disorders (e.g. achalasia)
Which cause does progressive dysphagia suggest?
Gradually growing stricture (could be malignant or benign)
What cause does intermittent dysphagia suggest?
Motility disorder
What does dysphagia to solids but not liquids suggest?
Mechanical obstruction (e.g. stricture) NOTE: if this stricture becomes more severe it could cause dysphagia to fluids as well
What does dysphagia that is worse with fluids than solids suggest?
Motility disorder
What does absolute dysphagia to solids, liquids and saliva suggest?
Foreign body obstruction (e.g. a bolus of food stuck in the oesophagus)
What does coughing immediately after swallowing suggest?
Problem with coordinating the swallow (e.g. due to stroke or Parkinson’s disease)
What does coughing some time after a meal suggest?
Regurgitation of food
What does nocturnal cough when patients are lying flat and not eating suggest?
Achalasia
What might halitosis in a patient with dysphagia suggest?
This occurs if food gets stuck in the oropharynx (e.g. in a pharyngeal pouch)
What can cause a gurgling noise when patients attempt to speak soon after eating/drinking?
Food stuck in a pharyngeal pouch could cause a gurgling noise
What can cause hoarseness of the voice in patients with dysphagia?
Vocal cord dysfunction due to involvement of the recurrent laryngeal nerve (e.g. compression by a pancoast lung tumour)
Why is it important to ask whether the patient has experienced heartburn or water brash?
These symptoms are associated with GORD
Why is it important to enquire about neurological symptoms?
Neurological signs may indicate that functional dysphagia (e.g. due to stroke, Parkinson’s disease etc) is more likely
Why is it important to enquire about rheumatological symptoms?
Rheumatological signs may suggest that limited cutaneous systemic sclerosis is the cause of the dysphagia
What are the five main features of limited cutaneous systemic sclerosis?
Calcinosis Raynaud’s Phenomenon Oesophageal Dysmotility Sclerodactyly Telangiectasia
What are the two most important conditions to enquire about with regards to the patient’s past medical history? Explain why.
- GORD
Predisposes to oesophageal cancer and non-malignant strictures - Peptic Ulcer Disease
Can lead to scarring and strictures around the gastric cardia and lower oesophagus
List some important features of the drug history that should be noted.
Drugs that relax smooth muscle (e.g. CCBs, nitrated) – exacerbate reflux symptoms
Drugs that increase risk of PUD (e.g. NSAIDs, steroids, aspirin, bisphosphonates)
Physical examination is rarely useful for dysphagia. However, there are five main features that are important to check for. What are they?
Cranial nerve pathology
Signs of GI malignancy (e.g. Troisier’s sign, cachexia)
Neck mass (e.g. large pharyngeal pouch, retrosternal goitre)
Features of CREST syndrome
Koilonychia (associated with Plummer-Vinson syndrome)
What is the first-line investigation for high dysphagia?
Barium Swallow
What is the first-line investigation for low dysphagia?
OGD
Name a type of modified barium swallow that is sometimes used to investigate patients with functional high dysphagia.
Videofluoroscopy
Which important investigation is used to differentiate between different types of motility disorder?
Manometry – assesses the pressures in the lower oesophageal sphincter and the peristaltic wave
List some imaging modalities that may be used to stage oesophageal cancer.
Spiral CT Chest/Abdomen
PET
Endoscopic Ultrasound
Laparoscopy
What is the main treatment for oesophageal cancer?
Oesophagectomy
What percentage of oesophageal cancer patients are UNsuitable for surgery?
60-70%
Define achalasia.
Failure of relaxation of the lower oesophageal sphincter
Describe the typical history of a patient with achalasia.
Young patient, no loss of weight, a long history of mild dysphagia to both solids and liquids with no problems coordinating the swallow in the mouth but the food/drink feels like it gets stuck on the way down to the stomach
List some treatment options for achalasia.
Pneumatic balloon dilation
Surgical (Heller’s) myotomy
Botox injections
Drugs (e.g. CCBs and nitrates)
