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

Presentation

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.

Aetiology

Investigations

• FBC and erythrocyte sedimentation rate (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 be pushed through a possible malignant stricture until its full extent has been assessed with barium swallow; thus, often both investigations are performed.

• MRI scanning 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 (require swallowing a catheter containing a pressure transducer) are useful when oesophageal spasm is suspected.

Management

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.⁵
Neurological problems, e.g. cerebrovascular event, may be helped by involving a speech therapist.⁶

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 replacement⁷, laser photocoagulation and injection of sclerosants. Surgical myotomy and endoscopic injection of the sphincter with botulinum toxin are occasionally used for some aetiologies.

Complications

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

Document references

1. Dent J, Holloway RH and Neale G in Oxford Textbook of Medicine, 4th Edition. Eds; Warrell DA et al. OUP 2003
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. [abstract]
4. Referral for suspected cancer, NICE Clinical Guideline (2005)
5. Hill M, Hughes T, Milford C. Treatment for swallowing difficulties (dysphagia) in chronic muscle disease. Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD004303. DOI: 10.1002/14651858.CD004303.pub2.
6. Management of patients with stroke: Identification and management of dysphagia, Scottish Intercollegiate Guidelines Network (SIGN), June 2010
7. Sreedharan A, Harris K, Crellin A, et al; Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD005048. [abstract]

Internet and further reading

• Gastrointestinal (upper) cancer - suspected, Clinical Knowledge Summaries (2005)
• Zervos X et al; Esophageal Webs and Rings, eMedicine, Nov 2008
• Consensus guideline on the medication management of adults with swallowing difficulties, Various Authors - Supported by an educational grant from Rosemont Pharmaceuticals Ltd (2006)

Acknowledgements