2 Dysphagia

Definition
Dysphagia literally means difficulty with swallowing, which may be associated with ingestion of solids or liquids or both.
KEY POINTS
• Most causes of dysphagia are oesophageal in origin.
• In children, foreign bodies and corrosive liquids are common causes.
• In young adults, reflux stricture and achalasia are common.
• In the middle aged and elderly, carcinoma and reflux are common.
• Because the segmental nerve supply of the oesophagus corresponds
to the intercostal dermatomes, a patient with dysphagia can accurately
pinpoint the level of obstruction.
• Any new symptoms of progressive dysphagia should be assumed to be
malignant until proven otherwise. All need endoscopic or radiological
investigation.
• Tumour and achalasia may mimic each other. Endoscopy and biopsy
are advisable unless the diagnosis is clear.
Important diagnostic features
Mural
• Carcinoma of the oesophagus: progressive course, associated weight loss and anorexia, low-grade anaemia, possible small haematemesis.
• Reflux oesophagitis and stricmre: preceded by heartburn, progressive course, nocturnal regurgitation.
• Achalasia: onset in young adulthood or old age, liquids disproportionately difficult to swallow, frequent regurgitation, recurrent chest infections, long history.
• Tracheo-oesophageal fistula-recurrent chest infections, coughing after drinking. Present in childhood (congenital) or late adulthood (post trauma, deep X-ray therapy (DXT) or malignant).
• Chagas’ disease (Trypanosoma cruzi): South American prevalence, associated with dysrhythmias and colonic dysmotility.

• Caustic stricture: examination shows corrosive ingestion,
chronic dysphagia, onset may be months after.
• Scleroderma: slow onset, associated with skin and hair
changes.
Intraluminal
Foreign body: acute onset, marked retrosternal discomfort, dysphagia even to saliva is characteristic.
Extramural
• Pulsion diverticulum: intermittent symptoms, unexpected
regurgitation.
• External compression: mediastinal lymph nodes, left atrial
hypertrophy, bronchial malignancy.

KEY INVESTIGATIONS

All

EBO: anaemia (tumours much more commonly cause this than reflux). LETs: (hepatic disease).

OGD

(moderate risk, specialist, good for differentiating tumour vs. achalasia vs. reflux stricture, allows biopsy for tissue diagnosis,
allows possible treatment).
Barium swallow
(low risk, easy, good for possible fistula, high tumour, diverticulum, reflux).

If ?dysmotility
• achalasia
• neurogenic causes

If ?extrinsic compression

Video barium swallow
Oesophageal manometry

CXR (AP and lateral) CT scan: low risk, good for extrinsic compression, allows tumour staging