Surgery - Dysphagia and odynophagia

Question 1

Dysphagia and odynophagia

Clinical presentation

Answer 1

• Dysphagia is the term for difficulty in swallowing.
• Fibrous foods such as chunks of meat, usually cause the most trouble.
• The patient can usually indicate a precise level for the perceived obstruction.
• The true level of obstruction is usually some distance below that point.

Question 2

Dysphagia and odynophagia

Causes of dysphagia

Obstruction arising in the oesophageal wall

Answer 2

Obstruction arising in the oesophageal wall
Common:

• Peptic oesophagitis (often associated with hiatus hernia)—sometimes causes fibrous stricture
• Carcinoma of oesophagus or cardia (uppermost part) of the stomach

Uncommon:

• Candida oesophagitis, particularly after major surgery

Extremely rare:

• Pharyngeal pouch
• Oesophageal web (Plummer–Vinson/Paterson–Kelly syndrome)
• ‘Oesophageal apoplexy’ due to haematoma in the wall
• Leiomyoma of the oesophageal muscle

Question 3

Dysphagia and odynophagia

Causes of dysphagia

Disorders of neuromuscular function

Answer 3

• Achalasia—uncommon
• Bulbar or pseudobulbar palsy—rare
• Myasthenia gravis—rare

Question 4

Dysphagia & Odynophagia

External compression of the oesophagus

Answer 4

• Subcarinal lymph node secondaries from carcinoma of the bronchus—fairly common
• Left atrial dilatation in mitral stenosis—rare
• Dysphagia lusoria (compression from abnormally placed great arteries)—very rare

Question 5

Dysphagia & Odynophagia

Approach to investigation of dysphagia

Answer 5

• A plain chest X-ray should be taken to exclude bronchial carcinoma; occasionally an oesophageal fluid level behind the heart is seen, resulting from an oesophageal stricture, hiatus hernia or achalasia.
• In high dysphagia, flexible pharyngoscopy followed by a barium swallow and meal is the usual sequence of investigation.
• In lower dysphagia, flexible endoscopy (OGD) is usually performed, as this allows direct inspection and biopsy; however, contrast radiography can be helpful.
• In disorders of function, swallowing barium-soaked bread or a video record of a barium swallow may be diagnostic.
• Oesophageal physiology measurements using manometry and pH monitoring are helpful in reaching a diagnosis of achalasia, especially in its early stages.