Dysphagia literally means ‘trouble swallowing’. It is not a condition in itself, but a symptom. There can be many causes varying from a muscular spasm or neurological cause, to oesophageal malignancy. As a result, any patient that presents with dysphagia needs to be thoroughly investigated for the possibility of malignancy.
Types of dysphagia
Pharyngeal / oesophageal
- Motor neurone disease
- Myasthenia gravis
- Upper oesophageal achalasia
- Cerebrovascular accident resulting in damage to 9th, 10th and 12th cranial nerves – this is the most common cause.
- Oesophageal spasm
- Luminal obstruction (e.g. due to stricture, bolus, carcinoma or perhaps trauma damage)
- Retrosternal goitre
- Lung cancer
- Pharyngeal diverticulum
- Vascular abnormalities – e.g. abdominal aortic aneurism, enlarged heart.
- Any type of mediastinal mass.
- Diabetes – can cause motility disorders in upper GI tract. Most commonly causes delayed gastric emptying,
Symptoms associated with dysphagia
- Chest pain due to oesophageal reflux
- Pain on swallowing – odynophagia – associated with oesophagitis
- Reflux of food or bile into the mouth – associated with severe GORD
- Coughing and aspiration of food – due to laryngeal or bulbar nerve palsy
- Palate incompetence – food goes into the nose when swallowing – associated with bulbar nerve palsy particularly after a cerebrovascular accident.
- Loss of weight / anorexia – suggests upper GI malignancy
- Hoarseness of voice – can be due to associated laryngeal malignancy, or as a result of laryngeal nerve palsy.
- Progressively worse dysphagia – suggests malignancy
- Difficulty swallowing solids but not liquids – suggests muscular incoordination
- Dysphagia with retrosternal pain and regurgitation – suggests stricture or carcinoma
- Dysphagia with weight loss – suggests malignancy
- Barium swallow – this gives very good views of the upper oesophagus, and thus will aid diagnosis of pharyngeal pouches and strictures, however often a negative result will be found, and this will require endoscopy. As a result, this test is rarely used, and endoscopy if the first investigation of choice.
- Endoscopy – this is actually quite risky compared to say endoscopy for gastric purposes, because things like pharyngeal pouches and strictures increase the risk of perforation. Strictures are often visible, and these can be diagnosed as benign or malignant. It may also be possible to diagnose achalasia if the oesophagus appears dilated in the presence of food residue.
- CT scan – this is rarely used as an investigation but may be regularly used to assess the level of malignancy.
- Endoscopic ultrasound – this is very useful at measuring things to do with the oesophageal wall. It cannot be performed if there is a narrowing at the top of the oesophagus because this prevents the passage of the instrument.
- 24Hr pH monitoring – this helps to see the amount of oesophagitis present and thus decided whether this may be a causing factor.
- The oesophageal sphincter will not relax properly, and so food cannot pass into the stomach in the normal manner
- The peristaltic contractions of the oesophagus do no propagate properly, and so the oesophagus will gradually become more and more dilated.
Barium swallow – this will produce a characteristic ‘bird’s beak’ appearance (see below)
Manometry – this is where the pressure within the oesophagus is measured.