Dysphagia
Gastroenterology
Introduction
Dysphagia is the medical term for difficulty in swallowing. It can affect the process of moving food or liquid from the mouth to the stomach, and may occur due to a variety of causes. People with dysphagia may experience pain or discomfort when swallowing, feel like food is stuck in their throat, or have trouble getting food or liquid down. One of the most sinister causes is oesophageal cancer. Other causes include:
Neuromuscular disorders such as myasthenia gravis or motor neurone disease
Obstructive disorders including:
Benign oesophageal stricture – associated with chronic GORD. Intermittent dysphagia with solids which worsens over time.
Pharyngeal pouch – sensation of lump in throat and halitosis.
Oesophageal motility disorders
Achalasia – dysphagia involving solids more than liquids.
Others:
Globus pharyngeus – this refers to a sensation of lump in throat along with anxiety. It is an example of a somatisation disorder.
Tonsillitis
WIPER
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Presenting Complaint
Use mnemonic STOP to qualify the nature of the dysphagia
S: Solids or liquids?
T: Timing – is it there all the time or is there a pattern to this?
O: Onset – When and how did it start?
P: Progression – Has it worsened over time? How long has it been going on for?
Other questions:
Does the food get stuck in your throat when swallowing?
Is there a lump in your throat?
Is there pain on swallowing? Do you have any burning or sharp pain in your chest
Have you noticed bad-smelling breath?
Do you have a sore throat or an acid taste in your throat (think GORD)
Is there any haematemesis or vomiting?
Have you noticed a change in your bowel habits? Any blood in your stools?
Have you had any weakness or pins and needles?
Is there a history of weight loss or loss of appetite.
ICE: Ideas, Concerns, Expectations
Ideas: Does the patient has any ideas what might be causing this?
Concerns: Are they worried about anything?
Expectations: What outcomes do they hope for?
Red Flags
Be sure to ask about ALARMS symptoms. These include:
Anaemia
Loss of weight
Anorexia
Recent onset of progressive symptoms
Melaena or haematemesis
Swallowing difficulty
55 years old
Past Medical History
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Medications
Current medications and recent changes:
NSAIDs
Corticosteroid
Family History
Ask specifically about neurological conditions such as multiple sclerosis or history of stroke.
Social History
Smoking
Alcohol Intake: How many units per week
Recreational Drugs
Lifestyle: Hot beverages?
Explore risk Factors for palpitations including:
Caffeine, alcohol, stress, thyroid problems, anaemia, and dehydration
Differential Diagnosis
The main differential diagnosis is an upper-GI malignancy.
Be sure to ask about ALARMS symptoms. These include:
Anaemia
Loss of weight
Anorexia
Recent onset of progressive symptoms
Melaena or haematemesis
Swallowing difficulty
55 years old
Management
If the patient has any ALARMS symptoms, arrange a 2-week wait referral.
Bedside:
Physical examination to check for
Assess pulse rate, rhythm, and volume
Blood pressure measurement
Complete neck and abdominal examination
Laboratory:
Blood Tests:
Full blood count (FBC) – anaemia or infection
Electrolytes – potassium, magnesium, calcium imbalances
Liver Function Tests
Imaging and Special Tests:
Chest X-ray
Barium swallow test
Endoscopy with biopsy
Videofluoroscopy to evaluate for aspiration
Staging CT scan, if indicated by earlier test results