Dysphagia (Including Oesophageal and Gastric Cancer)

Question 1

What are the causes of Dysphagia

Answer 1

Mechanical obstruction – Pharyngeal Carcinoma, Oesophageal (Squamous Cell or Adeno) Carcinoma, Gastric Carcinoma, Oesophageal stricture, Peptic Stricture, Pharyngeal Pouch
External compression – Bronchial Cell Carcinoma, Retrosternal Goitre, AAA
Motility Disorder/Neuromuscular Disorder – Achalasia, Diffuse Oesophageal Spasm, Systemic Sclerosis, Myasthenia Gravis, Parkinson’s

Question 2

What will you ask in a history of Dysphagia

Answer 2

Specific Questions to ask:
Was there difficulty swallowing liquids/solids from the start? - If yes (Think Achalasia), If No (Think Mechanical Obstruction)
Is it difficult to initiate swallowing movement? – If Yes (Think Neurological problem), If No (Think mechanical Obstruction)
If swallowing painful? – If yes (Think mechanical)
Is swallowing problems constant? – If yes (Think Mechanical Obstruction), If No (Think Oesophageal Spasm)
Does the neck bulge/gurgle during eating? – If yes (Think Pharyngeal Pouch)
Any constitutional symptoms of cancer – Anorexia/Weight loss – Oesophageal/Gastric Cancer
History of long standing reflux that slowly progressed to dysphagia – Think Oesophageal stricture or cancer
Risk Factors for oesophageal cancer – Elderly, Male, Smoking, Barret’s, GORD, Family History, Low fruit/veg diet
Risk factors for gastric cancer – Elderly, PPI use, Pernicious Anaemia, H. Pylori, Smoking, High Salt diet (Japanese), High pickle diet (Finish)
Are you bringing anything up – Unaltered food (Think Neuromuscular as has not reached stomach)
Most patients with a gastric or Oesophageal Cancer present late – Most patient do not present with dysphagia but rather the symptoms of any metastasise, so do a good systems review
What level is the dysphagia at – Difficulty initiating swallow/base of the neck (Oropharyngeal Dysphagia, commonly Neuromuscular disorder), Food sticks part way down after swallowing began (Oesophageal Dysphagia)

Question 3

What will you find on examination of a patient with dysphagia

Answer 3

Any signs are very late and so very poor prognosis
Hands:
Koilonychia - Iron Deficiency Anaemia
Neck:
Raised Virchow’s Node
Face:
Angular Stomatitis - Iron deficiency anaemia
Abdomen:
Epigastric Mass
Epigastric Tenderness
Hepatomegaly/Splenomegaly/Jaundice/Ascites - Metastasise or Obstruction
Legs:
Restless Leg syndrome - Iron deficiency anaemia

Question 4

What investigations will you order in Dysphagia?

Answer 4

Refer all patients with dysphagia via a 2 Week Wait referral
Bloods:
FBC – Looking for any anaemia that could be due to blood loss
U&E - In advanced disease patients are dehydrated with hypokalaemia because of their inability to swallow fluids and their saliva (potassium-rich)
LFT’s – Will show any metastasise
Calcium – May be raised

Imaging:
Barium swallow – To ensure there is no complete obstruction that an endoscope will not be able to pass through. Achalasia will show “Bird Beak” sign
Upper GI endoscopy with biopsy – Diagnostic test
CT/MRI for staging

Special Tests:
Manometry to rule out neuromuscular disorders
Peritoneal washout with cytology - Looking for cancerous cells indicating Mets
Endoscopic Ultrasound – Can be used to assess depth of invasion of any cancers in staging

Question 5

What is the treatment of Oesophageal Cancer?

Answer 5

Oesophageal cancers tend to present late so have a poor prognosis
Low grade T1/2 - Radical Oesophagectomy +/- pre-op chemo
Higher grade or unable to undergo surgery - Radio and chemotherapy
Palliative– Stenting/Chemo to allow swallowing and improve QOL

Question 6

What is the treatment of gastric cancer?

Answer 6

Gastric cancers tend to present late so have a poor prognosis
Localised Tumours (Surgical Patient) - Total or Subtotal Gastrectomy with Pre-Op chemo or Post-Op radiotherapy in higher staging
Localised Tumours (Non-Surgical Patient) - Chemotherapy
Palliative Patients - Chemotherapy, radiotherapy or palliative gastrectomy

Question 7

What is the treatment of the non malignant causes of dysphagia?

Answer 7

Strictures - Endoscopic Dilation
Achalasia – Heller Myotomy surgery, or Calcium channel blockers to reduce the LOS
Oesophageal spams – Calcium Channel Blockers