Dysphagia

Question 1

CREST, i.e. limited cutaneous scleroderma causes which type of dysphagia

Answer 1

Low functional dysphagia

Question 2

What two conditions do you need to ask about in patients who have dysphagia and why

Answer 2

GORD and peptic ulcers

GORD predisposes to eosophageal carcinoma and non-malignant strictures of the eosophagus

Peptic ulcers can lead to scarring and strictures around the gastric cardia and lower eosophagus

Question 3

Why is a drug history important with dysphagia?

Answer 3

CCBs and nitrates relax smooth muscle and can exacerbate reflux symptoms

NSAIDS/bisphosphonates/aspirin/steroids prediscpose to peptic ulceration

Question 4

What is the medical term for pain on swallowing

Answer 4

Odynophagia

Question 5

What is ortner’s syndrome

Answer 5

Cardiovocal syndrome or Ortner’s syndrome is hoarseness due to left recurrent laryngeal nerve palsy caused by mechanical affection of the nerve from enlarged cardiovascular structures.

The enlarged structures can then also cause dysphagia

Question 6

What is dysphagia lusoria

Answer 6

abnormal condition characterized by difficulty in swallowing caused by an aberrant right subclavian artery

Question 7

Why do you care about coughing in a dysphagia HX

Answer 7

If coughs immediately after swallowing, suggests problem with coordination of swallowing events (e.g. stroke/parkinson’s)

If coughing some time after meal suggests regurg of food from pharyngeal pouch/GORD

Question 8

What does gurgling or dysphonia suggest with dysphagia

Answer 8

Patients with a pharyngeal pouch can
often be heard to make gurgling noises if they attempt to speak soon after eating or drinking. It may also be possible to see a visible bulging of the neck.

Question 9

Why are you worried about noctural cough/wheeze

Answer 9

Ofc can happen in asthma, GORD or post nasal drip

BUT

Can also be a feature of achalasia, because stasis of food and saliva in the eosophagus can result in aspiration

Question 10

“early dysphagia for liquids” means what

Answer 10

If the patient is able to swallow
fl uid as per normal but has diffi culty with solid food items (which feel as if
they are sticking†
) this points towards a mechanical obstruction, i.e. a stricture (benign or malignant). Of course, as the stricture becomes more severe
then the dysphagia may start to involve fl uids as well. Equally it is possible for
oesophageal cancer to present as a sudden ‘absolute’ dysphagia if a morsel
of food lodges above a critically narrowed lumen – in which case the patient
cannot even swallow saliva. If the dysphagia is initially more pronounced for
fl uids over solids then this suggests a motility disorder (e.g. achalasia or a neuromuscular condition).

Question 11

CREST syndrome involves? What is CREST aka

Answer 11

Calcinosis
Raynauds
Esophageal dysfunction
Sclerodactyly
Telangiectasia 

CREST aka limited cutaneous scleroderma

Question 12

What 2 conditions are really important to ask about in dysphagia

Answer 12

1. GORD- predisposes to carcinoma & benign strictures. Hx of fundoplication operation to tighten LOS in the case of hiatus hernia also signigicant because there may be post-operative dysphagia if it’s too tight
2. Peptic ulcers- leads to scarring and structures around the gastric cardia and lower eosophagus

Question 13

What is plummer vinson syndrome

Answer 13

The association of postcricoid dysphagia, upper esophageal webs, and iron deficiency anemia is known as Plummer-Vinson syndrome (PVS) in the United States and Paterson-Brown Kelly syndrome in the United Kingdom. [1, 2, 3, 4, 5] The term sideropenic dysphagia has also been used, because the syndrome can occur with iron deficiency (sideropenia), but it is not associated with anemia.

Question 14

What investigation would you do in somebody with a) high dysphagia b) low dysphagia c) motility

Answer 14

a. barium swallow/videoflouroscopy
b. endoscopy (this isn’t used in high because the region is blindly intubated in endoscopy, which could risk injury or perforation to pharyngeal pouch/ high eosophageal cancer)

c. Manometry: Manometry is the key investigation for diagnosing a motility disorder
and distinguishing between the diff erent types of motility disorders (e.g.
achalasia and nutcracker oesophagus). It is indicated when barium swallow and/or endoscopy are unremarkable, suggesting a cause other than
mechanical obstruction.

Question 15

What might achalasia look like on barium swallow

Answer 15

Bird beak

Question 16

“velvety epithelium in distal eosopjhagus”?

Answer 16

Barretts eosophagus

Question 17

Fitness assessment for surgery for eosophagectomy?

Answer 17

Eosophagectomy associated with the highest mortality of any elective surgical procedure, and only about a third
of patients are deemed suitable for surgery due to advanced disease or comorbidity.

If the tumour is judged to be suitable for radical treatment, it is necessary to
also perform a fi tness assessment for surgery with a combination of lung function
tests, arterial blood gas (ABG), electrocardiogram (ECG), exercise tolerance test ±
echocardiogram.