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PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Dysphagia

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

Presentation

Symptoms

NB: Steady worsening of dysphagia over a few weeks in an older patient suggests malignancy.

  • 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
Obstructive
Neurological Others
Investigations
  • 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.
Management

If cancer is a possibility - all cases need urgent assessment under '2 week rules' (DOH Guidelines for urgent referral).4

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.
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. NICE Clinical Guideline; Referral for suspected cancer. June 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.

Internet and further reading Acknowledgements EMIS is grateful to Dr Hayley Willacy for writing this article and to Dr Huw Thomas for earlier versions. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 677
Document Version: 21
DocRef: bgp24630
Last Updated: 14 May 2008
Review Date: 14 May 2010




















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PS - Health and Poverty

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See also MAKEPOVERTYHISTORY North East for details and links to campaigns against poverty.

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