Red flag symptoms - Dysphagia

History of progression of symptoms is crucial to determine diagnosis.

Oesophageal cancer (Photograph: SPL)
Oesophageal cancer (Photograph: SPL)

Difficulty swallowing foods or liquids is alarming for both the patient and clinician alike. An accurate history will usually identify those at higher risk of the most sinister diagnosis - oesophageal cancer.

History
Onset and progression of symptoms is crucial in establishing a likely diagnosis. Steady worsening of symptoms in an older patient, involving solids first and then liquids, points to a malignancy.

Alternatively, a history of dysphagia for solids and not liquids may suggest a stricture, whereas if symptoms have involved both solids and liquids from the start, a motility problem or neurological cause should be sought.

Ask about weight loss, a common although late sign of malignancy.

In addition, since the large majority of differential diagnoses would result in a painless dysphagia, identifying pain on swallowing should also lead you to suspect a malignant cause.

Try to get an accurate picture of the patient's specific difficulties; is there coughing or choking on eating? Is food regurgitated? Ask whether there is a history of recurrent pneumonia, as any aspirated food can lead to infection. Ensure a detailed neurological history is taken because diagnoses such as motor neurone disease and myasthenia gravis require more careful questioning.

In terms of the past medical history, ensure details on any rheumatological or neurological diagnoses are collected, as well as any previous history of dyspepsia or gastro-oesophageal reflux disease.

Examination
Begin by assessing the patient's nutritional status, including measurement of body weight. Examine the mouth and neck and palpate for cervical lymphadenopathy. Watch the patient swallow - does the neck bulge? Is there choking, drooling or any obvious discomfort? Check to see whether there is any muscle wasting and perform a full neurological examination, paying particular attention to the cranial nerves, gait, muscle strength and evidence of fatigue. Examine the skin for signs of systemic disease, taking care to look specifically for the signs of CREST (calcinosis, Raynaud's phenomenon, oesophageal dysfunction, sclerodactyly and telangiectasia).

Investigation
FBC, LFTs (including albumin) and inflammatory markers should be checked. The patient requires referral for endoscopy and/or barium swallow. If motility/neurological problems are suspected, oesophageal manometry is sometimes performed.

  • Dr Jourdier is a part-time GP in London
Possible causes
  • Oesophagitis with or without stricture
  • Cancer - oesophageal, gastric, pharyngeal
  • Post-cricoid web (Patterson-Kelly-Brown syndrome)
  • Oesophageal rings
  • Foreign body
  • Stroke
  • Achalasia
  • Diffuse oesophageal spasm
  • Syringomyelia or bulbar palsy
  • Myasthenia gravis
  • Multiple sclerosis
  • Motor neurone disease
  • Myopathy
  • Parkinson's disease
  • Pharyngeal pouch
  • External compression
  • CREST/ scleroderma

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