Dysphagia

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Causes of dysphagia

• Intraluminal:
  • Foreign body
  • Poylpoid tumour
• Intramural:
  • Benign stricture
    • GORD, caustic, radiotherapy
  • Malignant stricture
  • Tumour
  • Oesophagitis
  • Oesophageal spasm
  • Scleroderma
  • Pharyngeal pouch
  • Plummer-Vinson web
  • Schatzki ring
  • Achalasia (failure of lower of oesophageal sphincter relaxation)
• Extra-mural:
  • Lymph nodes
  • Rolling hiatus hernia
  • Retrosternal goitre
  • Bronchial carcinoma
  • Thoracic aortic aneurysm
  • Enlarged left atrium
• Systemic:
  • Myasthenia gravis
  • Stroke/TIAs
  • Bulbar/pseudobulbar palsy
  • Syringobulbia
  • Parkinson’s
  • Bulbar polio

 History in dysphagia

• Presenting complaint
  • Difficulty in swallowing
• History of presenting complaint
  • Onset
  • Progression
    • Gradual and progressive or intermittent (spasm or achalasia)
  • Solids/Liquids/Both
    • And was there dysphagia to both right from the start?
  • Odynophagia (pain on swallowing – cancer, oesophagitis or spasm)
  • Is initiation of swallowing difficult
    • Think bulbar palsy
  • Associated reflux/water brash symptoms
  • Regurgitation of food
  • Level where the food sticks
  • Constitutional symptoms
    • Weight loss, night sweats, anorexia
• Past medical history
  • Gastrointestinal surgery
  • Barrett’s oesophagus (premalignant condition for oesophageal carcinoma)
  • Neuromuscular disease
  • Hypertension
  • Cardiovascular disease
  • Rheumatological disease
• Medications
  • Bisphosphonates
  • NSAIDs
  • Steroids
• Allergies
• Family history
  • Oesophageal carcinoma
• Social history
  • Alcohol consumption
  • Smoking

 Examination in dysphagia

• Anaemia
• Lymphadenopathy
• Cachexia
• Jaundice/Hepatomegaly – potential liver metastases
• Scleroderma

 Initial investigations in dysphagia

• Blood tests:
  • Full blood count and haematinics
  • Urea and electrolytes
  • Liver function tests
• Chest x-ray
• Upper GI endoscopy (plus biopsy)
• Barium swallow

 Further management of dysphagia will depend on the cause but can include:

• Oesophagectomy (for early stage carcinoma)
• Endoscopic dilatation for strictures
• Antibiotic/antifungals for oesophagitis
• Oesophageal manometry testing for achalasia
• Treatment of any underlying systemic condition

Click here for medical student OSCE and PACES questions about dysphagia

Common dysphagia exam questions for medical students, finals, OSCEs and MRCP PACES

Click here to download free teaching notes on dysphagia: Presentation-Dysphagia

Perfect revision for medical students, finals, OSCEs and MRCP PACES