Dysphagia


DEFINITION
Diagnosis card.
Acute complete dysphagia management
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AETIOLOGY

Physiology
1. Voluntary: tongue raised pushing bolus back.
2. Reflex initiated via receptors (1s):
- pharyngeal constrictors contract pushing down bolus.
- tensor veli palatini pulls down soft palate, preventing food entering nasopharynx
- epiglottis closes larynx
3. Oesophageal phase (10s):
- peristalsis, then LOS opens.

Neuromuscular
Polio
Guillian-Barre
Neuropathies
Myasthenia Gravis
Myopathy, eg myotonic dystrophy
Other CNS / PNS problem

Extraluminal
Tracheo-oesophageal fistula
- coughing after drinking
Neoplasm eg lung
Lymphadenopathy
Pharyngeal pouch
Aortic aneurysm
Left atrial dilation
Vertebral osteophyte

Mural
Schatzki ring
Oesophagitis
Chaga's
- Trypanosoma cruzi, with dysrrhymias and colonic dysmotility.
Neoplasm
- esp carcinoma
Scleroderma
Achalasia
- liquids disproportionately difficult to swallow.
GORD scarring
Caustic / radiation stricture
Pill stricture (eg slow K, tetracyclines, oxybutinin)
Diffuse oesophageal spasm

Intraluminal
FB / food bolus.
Oesophageal webs (Fe deficit)

Key Points
Most causes are oesophageal
- in children, FB and corrosive liquids are common causes.
- in young adults, consider reflux stricture, achalasia.
- middle age: carcinoma and reflux are common.
Progressive dysphagia is maligancy until proven otherwise
- endoscopy and radiology standard.
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BIOLOGICAL BEHAVIOUR
As relevant to aetiology
The segmental nerve supply of the oesophagus corresponds to intercostal dermatomes
- hence pts can often accurately pinpoint the obstructing level.
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MANIFESTATIONS

History


Since when?
- Gradual / sudden?
- Progressive or static?
Mild or severe?
Any event associated with onset?
What?
- solids only?
- (solids and liquids from onset = usually a motor problem)
- other special foods that produce it?
- positional (eg scleroderma pts manage liquids upright).
Does the food leave the oropharynx / enter oesophagus without difficulty?
Is there a swelling in the neck?
Where does it feel it is getting stuck?

Regurgitation?
Reflux?
- sour / bitter taste in back of mouth
- heartburn?
- (causes strictures)
Pain? - site, nature etc.
Constipation?

Hoarseness?
- did it precede or follow the dysphagia?
Chest symptoms of aspiration?
- cough / sputum / choking.
Wheeze?
Hiccups? (distal oesophagus)

Weight loss?
Appetite?
Energy?
Nervous excitability (thyroid)?

Past illnesses
Cancer
Neuro disorders
CT disorders
Medication?
- eg slow K, tetracyclines can cause strictures.
- corrosive swallowing event.
Social
Smoking?
Alcohol?
Travel to South / Central America?
Family history?
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INVESTIGATIONS
Relevant bloods
- CBC and LFTs
CXR - lat and AP
- may show extrinsic compressor, stages tumours.
Endoscopy usual
Barium swallow
- low risk, easy, shows fistula, high tumour, diverticulum, reflux.
Motility studies
- eg shows achalasia, neurogenics
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MANAGEMENT
As per aetiology

Acute dysphagia
Admit
Rehydrate
Arrange contrast study / upper GI endoscopy for following day.
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