Dysphagia

Dysphagia is defined as difficulty in swallowing. It is usually associated either with pharyngeal or oesophageal disease.^1,2

Symptoms

• 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.

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.
• 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.

• Full blood count and ESR should be taken.
• Barium swallow and/or endoscopy with biopsy should be performed.
  

  NB: Although many patients with dysphagia are initially referred for endoscopy (often shorter waits and tissue diagnosis possible), it is not recommended that an endoscope is pushed through a possible malignant stricture until its full extent is assessed with barium swallow, thus often both investigations are performed.

• MRI may also be required before any surgery is considered e.g. if there is 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 (requires swallowing a catheter containing a pressure transducer) are useful when oesophageal spasm is suspected.

General

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 neuro-muscular conditions.⁵
Neurological problems e.g. cerebrovascular event may be helped by involving a speech therapist.

Surgical

Definitive treatment depends on cause - usually endoscopic dilation (either using bougies or inflatable balloon).

• In oesophageal carcinoma, palliative relief of dysphagia can be achieved with repeated dilatation, stent replacement, laser photocoagulation and injection of sclerosants. Surgical myotomy and endoscopic injection of the sphincter with botulinum toxin are occasionally used for some aetiologies.

• Malnutrition; nutritional support is often needed prior to treatment.
• Aspiration pneumonia may occur.
• Perforation may occur iatrogenically.