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.

Causes	Notes
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 Heartburn 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:

Classification	Examples
Extrinsic	Mediastinal massesCervical spondylosis
Oesophageal wall	AchalasiaDiffuse oesophageal spasmHypertensive lower oesophageal sphincter
Intrinsic	TumoursStricturesOesophageal webSchatzki rings
Neurological	CVAParkinson’s diseaseMultiple SclerosisBrainstem pathologyMyasthenia Gravis

Investigation

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.