Gastroenterology - Dysphagia: By Samantha Gray M.D.
Dysphagia, or difficulty swallowing, is almost always due to organic disease and should be taken seriously. The responses to a few questions can narrow your differential diagnosis, and allow you to investigate and treat appropriately. Is the dysphagia esophageal or oropharyngeal? • Esophageal dysphagia is the ability to initiate swallowing, but inability of food to move down the esophagus. • Oropharyngeal dysphagia is difficulty initiating swallowing. It can be associated with choking, coughing, or nasal regurgitation. When esophageal dysphagia is described, I then ask: • Is the dysphagia due to solids or to solid and liquids? • Difficulty with only solids is suggestive of mechanical dysphagia with a lumen that is narrowed. If there is an advanced obstruction, the dysphagia can occur with solids or liquids.
• Difficulty with solids and liquids from the onset is more indicative of a neuromuscular disorder, such as diffuse esophageal spasm, scleroderma (which is an autoimmune disorder that can also cause “hardening of the skin), or achalasia – which is the failure of the smooth muscle fibres to relax. • What is the duration and course of symptoms? Most importantly, is it intermittent or progressive? • For mechanical obstruction, progressive dysphagia lasting a few weeks to months is worrisome for malignancy or peptic stricture. Malignancies typically progresses faster than inflammatory strictures. Intermittent dysphagia lasting several years is more indicative of a benign disease process such as a lower esophageal ring. • For neuromuscular disorders, progressive dysphagia is more indicative of scleroderma or achalasia, whereas intermittent dysphagia is more indicative of diffuse esophageal spasm. • Are there any associated symptoms? • For mechanical obstruction, weight loss is more indicative of malignancy whereas heartburn or reflux is more often associated with peptic stricture. • For neuromuscular disorders, chest pain is usually seen with diffuse esophageal spasm, whereas a history of reflux is usually seen with scleroderma. Any patient who presents with dysphagia to solids that is progressive over a few weeks, should be referred urgently for barium swallow and upper endoscopy to look for malignancy.
Do not wait until the patient is losing weight, or no longer able to swallow liquids, as they likely have advanced disease.
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