Dysphagia

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Dysphagia is defined as difficulty in swallowing. It is usually associated either with pharyngeal or oesophageal disease.[1][2] There is a spectrum of possible aetiologies (see links in table under Aetiology, below), from self-limiting illness (eg, tonsillitis) to carcinoma. It may occur with odynophagia - painful swallowing.

Symptoms

NB: steady worsening of dysphagia over a few weeks in an older patient suggests malignancy.
  • As well as the feeling of food sticking in the gullet, patients with oesophageal disease may have other symptoms. These range from discomfort to severe pain, with the patient nearly always unable to locate the obstruction accurately.
  • Regurgitation, vomiting, coughing and choking are common.
  • Men with new onset of alarm symptoms (loss of weight with worsening dysphagia) have an increased likelihood of a diagnosis of cancer, especially in those aged over 65.[3] A positive predictive value of 9.0% has been found in this age group.
  • The most common lesions within the oesophagus are inflammatory strictures from reflux or tumours.
  • A long history of heartburn is usually associated with an inflammatory stricture.
  • In Westernised countries, eosinophilic oesophagitis is thought to affect between 40 and 55 per 100,0000 population - similar to the numbers affected by Crohn's disease.[4] 
  • Idiopathic achalasia presents with dysphagia for solids and also regurgitation of a bland-tasting material that has never entered the stomach. It occurs in 1-2/100,000, most commonly seen in mid-adult life, and is caused by impaired neural control of the distal oesophagus.
Obstructive
  • Gastro-oesophageal reflux ± stricture.
  • Eosinophilic oesphagitis.
  • Other oesophagitis (eg, infection).
  • Oesophageal cancer.
  • Gastric cancer.
  • Pharyngeal cancer.
  • Post-cricoid web
    (Paterson-Brown-Kelly syndrome).
  • Oesophageal rings.
  • Foreign body (acute).
Neurological
  • Cerebrovascular event or brain injury.
  • Achalasia.
  • Diffuse oesophageal spasm.
  • Syringomyelia or bulbar palsy.
  • Myasthenia gravis.
  • Multiple sclerosis.
  • Motor neurone disease.
  • Myopathy (dermatomyositis, myotonic dystrophy).
  • Parkinson's disease and other degenerative disorders.
  • Chagas' disease.
Others
  • Pharyngeal pouch.
  • Globus hystericus.
  • External compression
    (eg, mediastinal tumour, or associated with cervical spondylosis).
  • Calcinosis, Raynaud's disease, (o)esophageal dysmotility, sclerodactyly, telangiectasia (CREST) syndrome or scleroderma.
  • Oesophageal amyloidosis.
  • Inflammation - eg, tonsillitis, laryngitis.

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  • FBC and erythrocyte sedimentation rate (ESR) should be taken.
  • Barium swallow and/or endoscopy with biopsy should usually be performed.
  • MRI scanning may also be required before any surgery is considered - eg, if there is oesophageal carcinoma.
  • Endoscopic ultrasonography can assist with staging in oesophageal carcinoma.
  • Videofluoroscopy is the radiological investigation of choice when 'difficulty swallowing' rather than 'food sticking' is the presenting symptom and/or aspiration is suspected.
  • Oesophageal motility studies (require swallowing a catheter containing a pressure transducer) are useful when oesophageal spasm is suspected.
If cancer is a possibility - all cases need urgent assessment under the 'two-week rules' (Department of Health guidelines for urgent referral).[5]

General

The patient may need to chew well or liquidise food.

There is insufficient evidence currently to support the efficacy of dietary modification, swallowing manoeuvres, surgical interventions or enteral feeding for the treatment of chronic neuromuscular conditions.[6] Neurological problems (eg, cerebrovascular event) may be helped by involving a speech therapist.[7]

Eosinophilic oesophagitis may be treated with dietary modification, topical steroids, leukotriene antagonists and other drugs, and endoscopic dilation.[4] 

Surgical

Definitive treatment depends on cause:

  • Strictures may be managed with endoscopic dilation (either using bougies or inflatable balloons).
  • If oesophageal carcinoma is diagnosed, staging will dictate whether curative surgery (for example, oesophagectomy) and chemotherapy are appropriate.[8] 
  • Overall, the five-year survival of patients with oesophageal carcinoma ranges from 15-25%.[8] 
  • In oesophageal carcinoma, palliative relief of dysphagia can be achieved with:
    • Repeated dilatation
    • Stent replacement[9] 
    • Laser photocoagulation
    • Injection of sclerosants
  • Brachytherapy can be a useful alternative or adjunct.
  • Surgical myotomy and endoscopic injection of the sphincter with botulinum toxin are occasionally used for some aetiologies.

Further reading & references

  1. Dent J, Holloway RH and Neale G; Oxford Textbook of Medicine, 4th Edition
  2. Owen W; ABC of the upper gastrointestinal tract. Dysphagia. BMJ. 2001 Oct 13;323(7317):850-3.
  3. Jones R, Latinovic R, Charlton J, et al; Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database. BMJ. 2007 May 19;334(7602):1040. Epub 2007 May 10.
  4. Park H; An Overview of Eosinophilic Esophagitis. Gut Liver. 2014 Nov;8(6):590-597. Epub 2014 Nov 15.
  5. Referral for suspected cancer; NICE Clinical Guideline (2005)
  6. Hill M, Hughes T, Milford C; Treatment for swallowing difficulties (dysphagia) in chronic muscle disease. Cochrane Database Syst Rev. 2004;(2):CD004303.
  7. Management of patients with stroke: Identification and management of dysphagia; Scottish Intercollegiate Guidelines Network - SIGN (June 2010)
  8. Pennathur A, Gibson MK, Jobe BA, et al; Oesophageal carcinoma. Lancet. 2013 Feb 2;381(9864):400-12. doi: 10.1016/S0140-6736(12)60643-6.
  9. Sreedharan A, Harris K, Crellin A, et al; Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD005048.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Huw Thomas
Current Version:
Peer Reviewer:
Dr Jacqueline Payne
Document ID:
677 (v23)
Last Checked:
01/12/2014
Next Review:
30/11/2019