Red flag symptoms: Dysphagia

Advice on identifying potentially serious causes of dysphagia, clinical evaluation and when to refer.

Red flag symptoms

  • Drooling, inability to swallow saliva suggestive of complete obstruction; immediate referral may be needed
  • Rapidly progressive dysphagia without neurological findings may suggest oesophageal malignancy
  • Weight loss
  • Focal neurological deficit
  • Dysphagia and dyspepsia
  • Hoarse voice

Dysphagia, difficulty in swallowing, refers to the transit of food and liquid as well as oral secretions from the pharynx to the stomach.

It may be complicated by aspiration pneumonia. Recurrent or chronic dysphagia may affect nutrition, leading to weight loss.

The condition can occur in up to 10% of the general population over the age of 50; the incidence is considerably higher in the elderly.1

Gastroesophageal reflux disease (GORD) is the major cause in younger individuals, whilst oropharyngeal dysphagia (OD) secondary to cerebrovascular disease is more frequent in the elderly.

If abnormal functioning arises from the proximal oesophagus, there is OD.2 This may present with difficulty in initiating swallowing, nasal regurgitation and aspiration.

This may arise due to neurological disorders, such as stroke, MS, Parkinson's disease and motor neurone disease (MND). Muscular disorders, such as myasthenia gravis, dermatomyositis and muscular dystrophy, may also cause it.2

If abnormal functioning arises beyond the proximal oesophagus, this is referred to as oesophageal dysphagia, which may be caused by a mechanical obstruction, or problems with motility.2

Motility disorders include achalasia and systemic sclerosis (as part of CREST syndrome, a form of systemic sclerosis characterised by Calcinosis, Reynaud's phenomenon, Esophageal dysmotility, Sclerodactyly and Telangiectasia). Dysphagia is frequently reported by patients with Sjogren's syndrome, systemic lupus erythematosus (SLE), mixed connective tissue disease and rheumatoid arthritis.3

Oesophageal stricture or webs, as well as malignancy, are the most common causes of mechanical obstruction.

It is important to note that an enlarged left atrium, aortic aneurysm or thoracic malignancy may result in extrinsic compression of the oesophagus, thereby leading to dysphagia.2

The incidence of swallowing difficulties may increase with age, due to a decline in oral motor function.4

Possible causes of dysphagia

  • Infective/inflammatory Oesophageal candidiasis, epiglottitis, retropharyngeal abscess2
  • Obstructive Oesophaeal/pharyngeal malignancy, peptic stricture, post-cricoid web, foreign body — food bolus obstruction
  • Neurological Cerebrovascular accident, bulbar palsy, myasthenia gravis, MS, MND, Parkinson's disease, myopathy4
  • Other Pharyngeal pouch, external compression of oesophagus, connective tissue disease — scleroderma

Clinical evaluation

Assessment of dysphagia should include noting when and how the symptoms started.

It may be helpful to assess where the patient feels the level of obstruction. Those with oesophageal dysphagia may report that food is sticking at the level of their lower neck or mid-chest.2 The patient may report vomiting or associated pain.

It is important to ask whether dysphagia is caused by solids or liquids. Dysphagia related to solids may be suggestive of mechanical obstruction. Nasal regurgitation, drooling, coughing or choking during meals are relevant and may be suggestive of an oropharyngeal disorder.2

Systemic review should include weakness and any associated fatigue, tremor and speech disturbance. There may also be shortness of breath or a hoarse voice.

Fatigue may point towards a diagnosis of myasthenia gravis.

Muscle fasciculation with wasting and weakness may suggest MND.4

Chest pain or heartburn may be suggestive of gastro-oesophageal reflux disease. Recurrent chest pains associated with meals, particularly with extremes of temperature, may suggest diffuse oesophageal spasm.2

Regurgitation of undigested food, halitosis, intermittent dysphagia and hypersalivation in an elderly patient may be suggestive of the presence of a pharyngeal pouch.2

Achalasia may be slowly progressive over many months and may be associated with nocturnal regurgitation. Enquiring about muscle and joint pains, Raynaud's phenomenon and any rashes may be relevant if a connective tissue disorder is suspected as a cause of dysphagia.

Dysphagia in a young male may point towards a diagnosis of eosinophilic oesophagitis.2 Eosiniphilic oesophagitis is a chronic allergen driven immune-mediated disease that is increasingly recognised as a cause of dysphagia. Past medical history may help elucidate the cause.

Physical examination may include assessing BMI. Neurological examination may be relevant, for example, there may be evidence of muscle wasting and/or fasciculation.

Joint and skin examination may be helpful if a connective tissue disorder is suspected. Neck examination to assess for goitre and cervical lymphadenopathy is important.

Management

Patients of any age presenting with dysphagia should be offered endoscopy under the two-week wait to rule out oesophageal or stomach cancer.5

Oesophageal biopsies are important to rule out eosinophilic oesophagitis.2 If upper GI endoscopy is not feasible, a barium swallow may be considered. In the majority of cases, endoscopy is normal or demonstrates mild erosive disease.3 If these investigations are negative, oesophageal motility studies may be helpful.

The suspected clinical diagnosis will guide further investigations, such as blood tests. Once a malignant process is excluded, the aims of treatment are to avoid aspiration or food bolus impaction, and minimise the morbidity associated with ongoing symptoms.3

  • Dr Kochhar is a GP in Bexhill, East Sussex

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References

  1. Holland G, Jayasekeran V, Pendleton N et al. Dis Esophagus 2011; 24(7): 476-80
  2. Charous SJ. Assessment of dysphagia. BMJ Best Practice 2017
  3. Philpott H, Garg M, Tomic D et al. World J Gastroenterol 2017; 23: 6942-6951
  4. Al-Hussaini A, Latif EH, Singh V. Clin Otolaryngol 2013; 38: 237-43
  5. NICE. Suspected cancer: recognition and referral. NG12. London, NICE, June 2015

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