Dysphagia refers to difficulty in swallowing. It is becoming an increasingly common presentation in Western countries, largely due to an aging population.
Unless the history is very convincing otherwise, dysphagia is oesophageal cancer until proven otherwise, and most patients presenting with dysphagia need an urgent upper GI endoscopy
In this article, we shall look at the causes, clinical assessment and management of a patient with dysphagia.
The causes of dysphagia can be divided into mechanical obstructions or neuromuscular / motility disorders (Table 1).
|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|
Table 1 – Causes of Dysphagia
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?
*Research 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.
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. These patients can become malnourished quickly so assessing their nutritional status is also essential.
All patients should be sent for an endoscopy ±biopsy to exclude any potential malignancy as a priority. Routine bloods, including FBC and LFTs, may also be required if malignancy is suspected.
If the endoscopy is normal and a motility disorder is suspected, manometry and 24hr pH studies will be required. If a pharyngeal pouch (or any other diverticulum) is suspected, barium swallow studies can be performed
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
Non-urgent referral is recommended with haematemesis or ≥55yrs with treatment resistant dyspepsia or upper abdominal pain*.
*Although the risk of oesophageal cancer rises with age, 10% of patients in the UK are under the age of 55
The mainstay of management in dysphagia is treatment of the underlying cause.
As a broad overview, treatment of malignancy is via surgical excision or palliation (with chemotherapy or stents), 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.
- Dysphagia causes can be categorised into mechanical or neuromuscular
- Most cases of dysphagia should be investigated with an urgent OGD
- Ensure early involvement of Speech and Language Therapists and Dieticians in cases of ongoing dysphagia