Dysphagia Flashcards
What is the difference between dysphagia and odynophagia
Dysphagia = difficulty swallowing Odynophagia = painful swallowing. Can be due to malignancy but more commonly candidiasis
Dysphagia can be categorised into high dysphagia (oropharyngeal and upper oesophagus) and low dysphagia (lower oesophageal). What are common causes of high dysphagia and low dysphagia
High dysphagia - Parkinsons disease, stroke
Low dysphagia - achalasia
If there is new onset dysphagia in Middle Aged to elderly patients what must be ruled out
Carcinoma (pt treated as carcinoma until proven otherwise)
What questions are important to ask about the swallowing
- Duration of symptoms - cancer = days to weeks. Chronic motility disorder = months to years
- Is dysphagia progressive or intermittent? - progressive dysphagia indicates stricture (benign/malignant). Intermittent = motility disorder
- Dysphagia to solids/liquids/both? - if fluid fine but solid food difficult -> mechanical obstruction (Eg stricture) -> can progress to difficulty with fluids too. If fluids more difficult than solids - motility disorder (e.g. achalasia/NMD). Absolute dysphagia to solid/liquid/saliva = food bolus stuck.
What associated symptoms should be asked about in history?
- Coughing? If so, related to eating? - coughing after swallowing (i.e. choking) = stroke/Parkinsons as disco ordination between swallowing events. If coughing a while after a meal - regurgitation of food within pharyngeal such / aspiration via dilated oesophagus e.g. achalasia / GORD. Nocturnal cough = achalasia
- Is there halitosis (bad breath) - food remains lodged in oropharynx - pharyngeal pouch
- Gurgling/dysphonia? - gurgling suggests pharyngeal pouch (may also see visible neck bulge). Hoarseness - e.g. if tumour compresses recurrent laryngeal nerve
- Heartburn/waterbrash? - GORD
- Weight loss - red flag oesophageal cancer
- Neurological symptoms
- Rheumatological symptoms - CREST syndrome
What aspects of the PMH is important
- Hx of GORD / GORD symptoms - GORD predisposes to oesophageal adenocarcinoma. Or GORD can occur after operation for sliding hiatus hernia.
- Peptic ulcers - can lead to scarring and strictures around gastric cardia and lower oesophagus
What aspects of the drug Hx are important to know
- CCBs / nitrates relax smooth muscle can cause/worsen reflux by decreasing oesophageal tone
- NSAIDS/aspirin/steroids/bisphosphonates predispose to peptic ulcers
On examination of a patient with dysphagia, what is important to look at?
- Cranial nerve pathology - ?bulbar palsy
- GI malignancy signs - cachexia, virchows node, hepatomegaly
- Neck mass - can palpate large pharyngeal pouch in thin patients, gurgling?
- Features of CREST syndrome
- Koilonychia - suggests iron deficiency anaemia - ?Plummer-Vinson syndrome (oesophageal webs) = very rare
What are the 4 main investigations for dysphagia and what are their indications
- Barium swallow - to investigate patients with a high lesion or achalasia symptoms (e.g. intermittent symptoms, difficulty with fluids and solids)
- Endoscopy - often first-line for low dysphagia
- Videofluoroscopy - functional high dysphagia
- Manometry - assesses pressure in lower oesophageal sphincter and peristaltic wave in rest of oesophagus. Key investigation to diagnose motility disorder and distinguish between different types of motility disorders. Indicates when barium swallow and/or endoscopy are unremarkable
What imaging modalities are used to stage an oesophageal adenocarcinoma?
Staging = how far cancer has spread anatomically Grading = histopathologically how different are the cells from normal
- Spiral CT chest/abdo
- PET scan
- Endoscopic ultrasound
- Laparoscopy
A birds beak appearance on a barium swallow is a classical sign for?
Achalasia.
But should still do manometry to distinguish achalasia from other motility disorders e.g. nutcracker oesophagus
What treatment is given for someone with achalasia
No treatment can restore full peristaltic function to oesophagus - we aim to loosen oesophageal sphincter
- Pneumatic balloon dilation
- Surgical myotome
- Botox injections
- Drugs e.g. CCBS/nitrates
