Dysphagia

Question 1

What is dysphagia until proven otherwise?

Answer 1

Oesophageal cancer which means most patients need an urgent upper GI endoscopy.

Question 2

Causes of dysphagia can be divided into obstruction or neuromuscular/motility disorders.

Give examples of mechanical disorders

Answer 2

Oesophageal or gastric malignancy

Benign oesophageal strictures

Extrinsic compression (e.g. from mitral stenosis)

Pharyngeal pouch

Foreign body

Oesophageal web

Question 3

Neuromuscular causes

Answer 3

Post-stroke

Achalasia

Diffuse oesophageal spasm

Myasthenia gravis

Myotonic dystrophy

Question 4

What questions to ask in history.

Answer 4

Ask about if there is difficulty in initiating swallowing

Cough after swallow?

Do you have to swallow a few times to get the food down your throat?

Important to differentiate from odynophagia as well

Ask about regurg, sensation of food becoming stuck, hoarse voice, weight loss or any referred ear or neck pain.

Question 5

Examinations

Answer 5

Do GI and resp examination

Assessment of nutritional status

Question 6

Laboratory tests

Answer 6

Routine bloods like FBC and LFTs especially if malignancy is suspected

Question 7

Important investigations

Answer 7

Endoscopy +/- biopsy to exclude malignancy.

Question 8

If endoscopy comes back normal and motility disorder is suspected, what should be done?

Answer 8

Manometry and 24hr pH studies will be required.

If a pharyngeal pouch is suspsected barium swallow studies can be performed.

Question 9

What does NICE recommend to send for urgent Upper GI endoscopy on 2 week wait referral.

Answer 9

Dysphagia

Aged >55y with weight loss + upper abdo pain/reflux/dyspepsia