Dysphagia

Dysphagia refers to difficulty in swallowing. It is becoming an increasingly common presentation in Western countries, largely due to an aging population.

In this article, we shall look at the causes, clinical assessment and management of a patient with dysphagia.


Aetiology

The causes of dysphagia can be divided into mechanical obstructions or neuromuscular / motility disorders (Table 1).

Mechanical

Neuromuscular

Oesophageal or gastric malignancy Post-stroke
Benign oesophageal strictures Achalasia
Extrinsic compression Diffuse oesophageal spasm
Pharyngeal pouch Myasthenia gravis
Foreign body (mainly in children) Myotonic dystrophy
Oesophageal web

Table 1 – Causes of Dysphagia


Clinical Features

In the assessment of dysphagia*, clarify the exact nature of the symptoms, such as:

  • Is there difficulty in initiating the swallowing action?
  • Do you cough after swallowing?
  • Do you have to swallow a few times to get the food to pass your throat?

N.B. Data has shown that asking between difficulty in swallowing solids versus liquids is  actually a poor differentiator between pharyngeal and oesophageal causes of dysphagia.

Any dysphagia should be differentiated from odynophagia (pain when swallowing), as a dysphagia may simply be due to a painful swallow, which has significantly different pathological causes.

Fig 1 - Posterior view of the oesophagus in the neck and thorax.

Fig 1 – Posterior view of the oesophagus in the neck and thorax.

Other symptoms to assess for include the presence of regurgitation, the sensation of food becoming ‘stuck’, a hoarse voice, weight loss, or any referred ear or neck pain.

On examination, inspect the mouth for any obvious oral pathologies and examine for any GI or respiratory disease that may impact on swallowing function.


Investigations

Unless the history is highly suggestive of a motility or neuromuscular disorder, patients should be sent for an endoscopy ±biopsy to exclude any potential malignancy.

FBC and LFTs may also be required if malignancy is suspected.

If a motility disorder is suspected, manometry will be required. If a pharyngeal pouch (or any other diverticulum) is suspected, barium swallow studies can be performed

Fig 2 - A non-cancerous peptic stricture, observed on endoscopy.

Fig 2 – A non-cancerous peptic stricture, observed on endoscopy.

Any further investigations will depend on the underlying cause identified.

Cancer Referral Pathway

In the UK, NICE recommends urgent upper GI endoscopy within 2 weeks to assess for oesophageal cancer in people:

  • With dysphagia
  • Aged ≥55yrs with weight loss plus
    • Upper abdominal pain
    • Reflux
    • Dyspepsia

Non-urgent referral is recommended with haematemesis or ≥55yrs with treatment resistant dyspepsia or upper abdominal pain.


Management

The mainstay of management in dysphagia is treatment of the underlying cause.

As a broad overview, treatment of malignancy is via surgical excision, laser or palliation, whereas motility disorders are treated by targeting the underlying cause and referral for swallowing therapy.

In cases where no immediate reversible cause is identified, referral to speech and language therapists and to dieticians is advisable.

Key Points

  • Dysphagia causes can be categorised into mechanical or neuromuscular
  • Most cases of dysphagia should be investigated with an urgent OGD, unless symptoms are highly suggestive of a neuromuscular cause
  • All patients with dysphagia should be referred on the 2-week referral pathway
  • Ensure early involvement of Speech and Language Therapists and Dieticians in cases of ongoing dysphagia

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