Dysphagia (difficulty swallowing)
Two main types:
In oropharyngeal dysphagia, case may present with ear pain (referred from a hypopharyngeal lesion)
Both solids and liquids => neuromuscular disorder
Initially solids and later liquids => mechanical obstruction such as malignancy
Next step is nasopharyngeal laryngoscopy
Remember that new-onset dysphagia is a red flag symptom that requires urgent endoscopy, regardless of age or other symptoms.
| 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 | There may be a 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 | There may be a history of anxiety Symptoms are often intermittent and relieved by swallowing Usually painless - the presence of pain should warrant further investigation for organic causes |
As with many conditions, it's often useful to think about causes of a symptom in a structured way:
| Classification | Examples |
|---|---|
| Extrinsic | • Mediastinal masses |
| • Cervical spondylosis | |
| Oesophageal wall | • Achalasia |
| • Diffuse oesophageal spasm | |
| • Hypertensive lower oesophageal sphincter | |
| Intrinsic | • Tumours |
| • Strictures | |
| • Oesophageal web | |
| • Schatzki rings | |
| Neurological | • CVA |
| • Parkinson's disease | |
| • Multiple Sclerosis | |
| • Brainstem pathology | |
| • Myasthenia Gravis |
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.