Dysphagia
The table below gives characteristic exam question features for conditions causing dysphagia:
As with many conditions, it's often useful to think about causes of a symptom in a structured way:
Investigation
All patients require an upper GI endoscopy unless there are compelling reasons for this not to be performed. Motility disorders may be best appreciated by undertaking fluoroscopic swallowing studies.
A full blood count should be performed.
Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.
| Causes | Notes |
|---|---|
| Oesophageal cancer | Dysphagia may be associated with weight loss, anorexia or vomiting during eating Past history may include Barrett's oesophagus, GORD, excessive smoking or alcohol use |
| Oesophagitis | May be history of heartburn Odynophagia but no weight loss and systemically well |
| Oesophageal candidiasis | There may be a history of HIV or other risk factors such as steroid inhaler use |
| Achalasia | Dysphagia of both liquids and solids from the start Heartburn Regurgitation of food - may lead to cough, aspiration pneumonia etc |
| Pharyngeal pouch | More common in older men Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles Usually not seen but if large then a midline lump in the neck that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen |
| Systemic sclerosis | Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased. This contrasts to achalasia where the LES pressure is increased |
| Myasthenia gravis | Other symptoms may include extraocular muscle weakness or ptosis Dysphagia with liquids as well as solids |
| Globus hystericus | May be history of anxiety Symptoms are often intermittent and relieved by swallowing Usually painless - the presence of pain should warrant further investigation for organic causes |
Causes of dysphagia - by classification
As with many conditions, it's often useful to think about causes of a symptom in a structured way:
| Classification | Examples |
|---|---|
| Extrinsic |
|
| Oesophageal wall |
|
| Intrinsic |
|
| Neurological |
|
Investigation
All patients require an upper GI endoscopy unless there are compelling reasons for this not to be performed. Motility disorders may be best appreciated by undertaking fluoroscopic swallowing studies.
A full blood count should be performed.
Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.