Dysphagia and Dyspepsia

Question 1

Dysphagia Differentials

Answer 1

GLOBUS HYSTERICUS:
- ?Hx of anxiety. Sx often intermittent and relieved by swallowing. Usually painless. Presence of pain warrants further Ix for organic cause

OESOPHAGEAL Ca:

• Dysphagia may be assoc w weight loss, anorexia, vomiting during eating
• PMHx > Barrett’s, GORD, Excessive smoking, ETOH

OESOPHAGITIS:
- ?Hx of heartburn, Odynophagia but no weight loss

OESOPHAGEAL CANDIDASIS:
- Odynophagia, Hx of ? HIV, ? Steroid inhaler

ACHALASIA:

• Dysphagia of BOTH solids and liquids from the start
• Lower Oesophageal Sphincter Pressure increased
• Heartburn
• Regurgitation of old food > cough, aspiration pneumonia

PHARNYGEAL POUCH

• More common in older men
• Represents a posteromedial herniation between thyropharyngeus and cricopharynxgeus muscles
• Usually not seen but if large then midline lump in neck- gurgles on palpation
• Typical Sx = dysphagia, regurgitation, aspiration, chronic cough, halitosis

SYSTEMIC SCLEROSIS

• Other features of CREST - Oesophageal dysmotility
• Lower oesophageal sphincter pressure decreased!

MYASTHENIA GRAVIS

• Other Sx of MG e.g. extra ocular muscle weakness, ptosis
• Dysphagia with solids and liquids

Question 2

Dyspepsia

Answer 2

2015 NICE Guidelines ‘suspected cancer recognition and referral’ updated the advice on who needs urgent referral for an endoscopy (i.e. within 2 weeks)

Advice for Oesophageal and Gastric Ca
URGENT:
- all patients who have Dysphagia
- all patients who have Upper Abdominal Mass consistent with stomach Ca
- patients aged >= 55 who have weight loss AND any of:
> upper abdom pain
> reflux
> dyspepsia

NON-URGENT:
- Patients with Haematemesis
- Patients aged >= 55 who have:
> treatment resistant dyspepsia
> upper abdom pain w low Hb
> raised platelet count
> nausea or vomiting

Undiagnosed Dyspepsia = those who do not meet referral criteria for urgent/non-urgent endoscopy referral:

1) Review meds for causes of dyspepsia
2) Lifestyle advice
3) Trial of PPI for one month OR ‘test and treat’ approach for H.Pylori

Testing for H.Pylori

• initial diagnosis: carbon-13 urea breath test OR stool antigen test OR lab-based serology
• test of cure: carbon-13 urea breath test