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Dysphagia

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Overview

Dysphagia describes the difficulty in swallowing solids or liquids. Some patients may describe the sensation as food sticking or getting stuck, choking, or aspiration. It is different to painful swallowing (odynophagia).

New-onset dysphagia is a red-flag symptom. Regardless of age, symptoms, and other features, urgent endoscopy is required. Any patient, regardless of age and other features, should be offered an urgent upper gastrointestinal endoscopy to be performed within 2 weeks.

Presentation

Patients may present with the following:

  • Regurgitation
  • Choking
  • Coughing
  • Vomiting

Steadily worsening dysphagia may suggest malignancy.

Referral

Any patient, regardless of age and other features, should be offered an urgent upper gastrointestinal endoscopy to be performed within 2 weeks.

Differential Diagnoses

Acute pharyngitis

  • Patients report odynophagia
  • Associated fever and malaise may be seen
  • Tonsillar erythema and/or exudates may be seen
  • Lymphadenopathy may be present

Oesophageal cancer

  • Dysphagia tends to affect solids more than liquids, however, as the disease progresses, dysphagia may affect both
  • Weight loss may be present and may be severe
  • Risk factors such as smoking, alcohol consumption, and longstanding and untreated GORD may be present

Gastro-oesophageal reflux disease (GORD)

  • Patients also report heartburn and acid reflux
  • No other exam findings are generally seen

Oesophagitis

  • Patients usually have preceding symptoms of gastro-oesophageal reflux disease (GORD)
  • Patients report odynophagia, but are otherwise well, and have no weight loss

Oesophageal candidiasis

  • Patients report odynophagia
  • There may be a predisposing risk factor (e.g. HIV, immunosuppression, inhaled corticosteroid use)

Achalasia

  • Dysphagia tends to affect both solids and liquids from the start
  • There may be associated regurgitation and heartburn
  • Patients may have coping mechanisms for dysphagia (e.g. sitting or standing up straight when eating)

Globus hystericus

  • Dysphagia is generally painless, intermittent, and relieved with swallowing
  • There may be a history of a psychiatric problem (e.g. depression or anxiety)
  • The presence of pain warrants further investigation

Pharyngeal pouch

  • Generally seen in older patients
  • A neck lump that gurgles on palpation may be seen
  • There may be associated regurgitation and cough
  • Halitosis may be seen

Systemic sclerosis

Myasthenia gravis

  • Features tend to progressively get worse after exertion or at the end of the day
  • Extraocular muscle weakness may be seen, which can cause diplopia
  • Ptosis and proximal muscle weakness may be seen on examination

Stroke

  • Associated coughing, choking, regurgitation, and drooling may be seen
  • Focal neurological deficits may be seen (e.g. paralysis, paraesthesia, vertigo, visual field defects)

Parkinson’s disease

  • Associated coughing, choking, regurgitation, and drooling may be seen
  • Cardinal (TRAP) symptoms of Parkinson’s disease may be present, such as Tremors, Rigidity, Akinesia or bradykinesia, and/or Postural instability

Multiple sclerosis

  • Associated coughing, choking, regurgitation, and drooling may be seen
  • Associated sensorimotor deficits may be seen, including vision loss due to optic neuritis, and spasticity
  • Urinary incontinence or retention may be seen

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