Presentation of

Aetiology of dysphagia  Intraluminal: o Foreign body o Poylpoid tumour  Intramural: o Benign stricture – GORD, caustic, radiotherapy o Malignant stricture o Tumour o Oesophagitis o Oesophageal spasm o Scleroderma o Pharyngeal pouch o Plummer-Vinson web o Schatzki ring o Achalasia (failure of lower of oesophageal sphincter relaxation)  Extra-mural: o Lymph nodes o Rolling hiatus o Retrosternal goitre o Bronchial carcinoma o Thoracic aortic aneurysm o Enlarged left atrium  Systemic: o Myasthenia gravis o Stroke/TIAs o Bulbar/pseudobulbar palsy o Syringobulbia o Parkinson’s o Bulbar polio

History in dysphagia  Presenting complaint o Difficulty in swallowing  History of presenting complaint o Onset o Progression . Gradual and progressive or intermittent (spasm or achalasia) o Solids/Liquids/Both . And was there dysphagia to both right from the start? o Odynophagia (pain on swallowing – cancer, oesophagitis or spasm) o Is initiation of swallowing difficult . Think bulbar palsy o Associated reflux/water brash symptoms o Regurgitation of food o Level where the food sticks o Constitutional symptoms . Weight loss, night sweats, anorexia  Past medical history o Gastrointestinal surgery

o Barrett’s oesophagus (premalignant condition for oesophageal carcinoma) o Neuromuscular disease o Hypertension o Cardiovascular disease o Rheumatological disease  Medications o Bisphosphonates o NSAIDs o Steroids  Allergies  Family history o Oesophageal carcinoma  Social history o Alcohol consumption o Smoking

Examination of dysphagia  Anaemia  Lymphadenopathy  Cachexia  / – metastases  Scleroderma

Initial investigations in dysphagia  Blood tests: o Full blood count and haematinics o Urea and electrolytes o Liver function tests  Chest x-ray  Upper GI endoscopy (plus biopsy)  Barium swallow

Further management of dysphagia will depend on the cause but can include  Oesophagectomy (for early stage carcinoma)  Endoscopic dilatation for strictures  Antibiotic/antifungals for oesophagitis  Oesophageal manometry testing for achalasia  Treatment of any underlying systemic condition

Common questions concerning dysphagia  Which red flag symptoms would make you think of a malignant cause? o Progressive (painful) dysphagia to solids and then liquids with associated constitutional symptoms  What is the characteristic finding on barium swallow in achalasia? o ‘Bird-beak sign’ – tapering of the distal end of the oesophagus