🩺 Dysphagia

Dysphagia is defined as difficulty in swallowing or the sensation of food being hindered in its passage from the mouth to the stomach. It is a high-risk symptom that frequently signals serious underlying pathology, including malignancy or progressive neurological decline. It is broadly divided into 'high' (oropharyngeal) and 'low' (oesophageal) dysphagia. In the UK, the focus of management is rapid exclusion of upper GI malignancy and prevention of complications such as aspiration, malnutrition, and dehydration.

Crucial to differentiate oropharyngeal (difficulty initiating swallow) from oesophageal dysphagia (food getting 'stuck' after swallowing). Ask: 'Does meat or bread get stuck?' (solids) and 'Does water cause issues?' (liquids). Progressing from solids to liquids suggests a structural narrowing (stricture/cancer); both from the start suggests a motility disorder (achalasia). Intermittent vs. constant symptoms are also key. Ask about reflux (GORD), weight loss (malignancy), and odynophagia (pain on swallowing - suggests oesophagitis). Drug history (bisphosphonates) is also relevant.

Examination is often unremarkable but must include a thorough check of the neck for lymphadenopathy (supraclavicular) or thyroid masses. Observe the patient swallowing a sip of water; coughing, choking, or a 'wet' voice suggests oropharyngeal dysphagia or aspiration. Check for signs of systemic disease like scleroderma (sclerodactyly, telangiectasia) or neurological signs (cranial nerve palsies, Parkinsonism, or stroke) that might cause bulbar or pseudobulbar palsy. Nutritional status should be assessed via BMI.

Oesophageal Carcinoma, Oesophageal Stricture (peptic), Achalasia, Diffuse Oesophageal Spasm, Eosinophilic Oesophagitis, Pharyngeal Pouch, Neurological causes (Stroke/MND), Bulbar Palsy.

Weight loss, odynophagia (painful swallowing), persistent symptoms, hoarseness, and anaemia.

The gold standard for suspected oesophageal dysphagia is an Oesophagogastroduodenoscopy (OGD) to directly visualise and biopsy any lesions. If oropharyngeal dysphagia or a motility disorder is suspected, a Barium Swallow or Videofluoroscopy is preferred. Oesophageal Manometry is the definitive test for motility disorders like achalasia (showing failed relaxation of the LOS). High-resolution CT may be required if extraluminal compression (e.g., lung cancer, goitre) is suspected. Routine bloods include FBC (anaemia).

Oesophageal 'web' or 'ring' may cause intermittent dysphagia specifically for solids, often associated with iron deficiency (Plummer-Vinson syndrome). In older patients, any new-onset dysphagia is 'cancer until proven otherwise.' A 'gurgling' sound in the neck or halitosis (foul breath) associated with dysphagia suggests a pharyngeal pouch (Zenker's diverticulum). Globus pharyngeus is the sensation of a 'lump in the throat' but is notably *not* associated with difficulty swallowing and is usually functional.

Dysphagia is a 'red flag' symptom. Under NICE NG12, any patient of any age with unexplained dysphagia must be referred on a 2-week wait (2WW) for urgent endoscopy. Students must understand the risk of aspiration pneumonia in patients with neurogenic dysphagia and the role of the SALT (Speech and Language Therapy) team in management. Recognise 'odynophagia' as distinct from dysphagia.