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 cancerDysphagia may be associated with weight loss, anorexia or vomiting during eating
Past history may include Barrett’s oesophagus, GORD, excessive smoking or alcohol use
OesophagitisThere may be a history of heartburn
Odynophagia but no weight loss and systemically well
Oesophageal candidiasisThere may be a history of HIV or other risk factors such as steroid inhaler use
AchalasiaDysphagia of both liquids and solids from the start
Regurgitation of food – may lead to cough, aspiration pneumonia etc
Pharyngeal pouchMore 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 sclerosisOther 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 gravisOther symptoms may include extraocular muscle weakness or ptosis
Dysphagia with liquids as well as solids
Globus hystericusThere 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:

ExtrinsicMediastinal massesCervical spondylosis
Oesophageal wallAchalasiaDiffuse oesophageal spasmHypertensive lower oesophageal sphincter
IntrinsicTumoursStricturesOesophageal webSchatzki rings
NeurologicalCVAParkinson’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.

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