The table below gives characteristic exam question features for conditions causing dysphagia. Remember that new-onset dysphagia is a red flag symptom that requires urgent endoscopy, regardless of age or other symptoms.
|Oesophageal cancer||Dysphagia may be associated with weight loss, anorexia or vomiting during eating|
Past history may include Barrett’s oesophagus, GORD, excessive smoking or alcohol use
|Oesophagitis||There may be a history of heartburn|
Odynophagia but no weight loss and systemically well
|Oesophageal candidiasis||There may be a history of HIV or other risk factors such as steroid inhaler use|
|Achalasia||Dysphagia of both liquids and solids from the start|
Regurgitation of food – may lead to cough, aspiration pneumonia etc
|Pharyngeal pouch||More common in older men|
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen
|Systemic sclerosis||Other features of CREST syndrome may be present, namely Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia|
As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased. This contrasts to achalasia where the LES pressure is increased
|Myasthenia gravis||Other symptoms may include extraocular muscle weakness or ptosis|
Dysphagia with liquids as well as solids
|Globus hystericus||There may be a history of anxiety|
Symptoms are often intermittent and relieved by swallowing
Usually painless – the presence of pain should warrant further investigation for organic causes
Causes of dysphagia – by classification
As with many conditions, it’s often useful to think about causes of a symptom in a structured way:
|Extrinsic||Mediastinal massesCervical spondylosis|
|Oesophageal wall||AchalasiaDiffuse oesophageal spasmHypertensive lower oesophageal sphincter|
|Intrinsic||TumoursStricturesOesophageal webSchatzki rings|
|Neurological||CVAParkinson’s diseaseMultiple SclerosisBrainstem pathologyMyasthenia Gravis|
All patients require an upper GI endoscopy unless there are compelling reasons for this not to be performed. Motility disorders may be best appreciated by undertaking fluoroscopic swallowing studies.
A full blood count should be performed.
Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.