An Approach to Dysphagia
Doctor I can't swallow ! An Approach to Dysphagia
Introduction
Differential diagnosis
Evaluation Priorities
Dysphagia Grading
Real Problem Scenarios
Context : Emergency Unit or OPD
Introduction
Patients who can’t swallow food will usually be able to accurately describe where they feel the level of obstruction is: either in the oro-pharynx or somewhere along the length of the oesophagus. Oro- pharyngeal conditions cause difficulty to initiate swallowing, whereas in true oesophageal dysphagia patients describe a normal swallowing reflex, and then will point to where the food seems to obstruct.
It is very important to ask if the dysphagia is constant and progressive or episodic, as the latter is more suggestive of motility disorders. Also enquire about pain on swallowing (odynophagia) which will be more suggestive of an inflammatory condition, such as esophagitis.
Occasionally patients with long-standing dysmotility may develop a “mega-oesophagus” that is able to collect a large volume of food- on regurgitation it may be similar to the contents of gastric outlet obstruction.
On examination pay specific attention to signs of dehydration, weight loss, anaemia, and supra-clavicular adenopathy. Look for thyroid and other neck masses, and do a neurological examination to rule out a bulbar or pseudobulbar palsy. Chest infections are common, from aspiration or occasionally broncho- oesophageal fistulae.
Abdominal examination is usually unremarkable.
Differential Diagnosis
Oropharyngeal These are primarily ENT or neurological conditions- they will seldom present de novo to a surgical unit, as the diagnosis is obvious in most cases | |
Common Causes | Unusual |
Latrogenic strictures post-radiotherapy or corrosives Neurological disorders
| In the lumen Oesophagal webs Oropharyngeal tumours In the wallZenker's diverticulum DysmotilityGlobus hystericus & myopathies |
Oesophageal The majority of cases in SA adults will be oesophagal carcinomas | |
Common Causes (>90%) | Unusual |
Carcinoma
GERD stricture
| In the lumen Food bolus or foreign body obstruction Oesophagal webs In the wallOther neoplasm (GIST/ Kaposi) ExtrinsicMediastinal adenopathy (TB/ lymphoma) Retrosternal goitre Aneurysm of the aortic arch DysmotilityAchalasia & other oesophagal dysmotility syndrome |
Evaluation Priorities
How bad is this?
- Some patients are overtly cachectic and need admission and urgent investigations. This is typical of advanced squamous carcinoma of the oesophagus. Most other cases can be managed and investigated as an outpatient.
- Rehydrate the patient and correct electrolyte derangements.
Dysphagia grading
| 1 | Complains of dysphagia, but can maintain normal diet |
| 2 | Requires liquids with meals |
| 3 | Eats semi -solids |
| 4 | Liquids only |
| 5 | Can swallow saliva only |
| 6 | Complete dysphagia |
What is the cause ?
Oesophageal carcinoma | Progressive dysphagia, marked LOW, cachectic |
GERD stricture | History of reflux precedes the onset of dysphagia |
Achalasia | Intermittent dysphagia to both liquids and solids |
Corrosive stricture | Psychiatric history, recent suicide attempt with ingestion of corrosives, previous dilatations |
What other investigations must I consider ?
True oesophageal dysphagia | Oropharyngeal dysphagia |
| The key investigation is an upper GI endoscopy. This will confirm the diagnosis and differentiate between oesophagal carcinoma and a reflux stricture. A barium swallow is also helpful Motility studies must be done in suspended achalasia | Nasopharyngeal endoscopy Dynamic videoflouroscopy |
Real Problem Scenarios
The endoscopy can’t see a mucosal lesion, there is nothing to biopsy!
- Book a CT scan to see if there is compression from mediastinal pathology
The oesophageal lesion looks like cancer, but the biopsy is negative!
- Discuss with your consultant
- How many biopsies were taken (a minimum of 4 must be taken in each case!)
- Consider a repeat endoscopy and re-biopsy
- Do a barium swallow
When must we intervene?
- Most cases are managed endoscopically, obviously depending on the cause.
- Squamous carcinomas are almost always irresectable, and patients are palliated by either
inserting a stent across the obstructing lesion or by radiotherapy - Adenocarcinomas are more likely to be considered for curative treatment and a combined
senior review of their cases must be done before definitive interventions are planned. - GERD and corrosive strictures are usually managed by serial oesophagal dilatations.