Dysphagia

Introduction

Dysphagia refers to difficulty in swallowing and can involve problems with the passage of food or liquid from the mouth to the stomach. It may be caused by neuromuscular dysfunction, structural obstruction, or oesophageal motility disorders. Dysphagia is an important symptom that can indicate serious underlying pathology such as oesophageal cancer, particularly in older adults.

Peak Incidence

• Most commonly affects individuals aged ≥55 years.
• Risk increases with age, GORD, neurological disease, and oesophageal malignancy.

Pathophysiology

Dysphagia is broadly divided into two types:

1. Oropharyngeal dysphagia (high dysphagia):
   • Difficulty initiating swallowing.
   • Often due to neurological causes (e.g. stroke, Parkinson’s disease, motor neurone disease).
2. Oesophageal dysphagia (low dysphagia):
   • Sensation of food sticking in the chest.
   • Can be due to structural causes (e.g. strictures, malignancy), motility disorders (e.g. achalasia), or inflammation (e.g. oesophagitis).

Symptoms

• Difficulty swallowing solids and/or liquids
• Sensation of food “sticking” in the throat or chest
• Odynophagia (painful swallowing)
• Heartburn or acid reflux
• Regurgitation or vomiting of food
• Haematemesis (vomiting blood)
• Melaena (black tarry stools – suggestive of upper GI bleeding)

Signs

• Weight loss (common in malignancy or longstanding dysphagia)
• Anaemia – pallor, fatigue, angular cheilitis (from chronic blood loss or malnutrition)
• Halitosis – may indicate food stasis (e.g. Zenker’s diverticulum)
• Epigastric tenderness – if GORD/gastritis present
• Cervical lymphadenopathy – may suggest malignancy
• Recurrent aspiration pneumonia – from oropharyngeal dysphagia

Diagnosis

Urgent Referral (2-Week Wait)

• All patients with dysphagia.
• Age ≥55 with weight loss and any of the following:
  • Upper abdominal pain
  • Dyspepsia
  • Reflux

Initial Management (<55 years with no red flags)

• Step 1: Lifestyle modifications
  • Avoid alcohol, caffeine, smoking
  • Reduce stress
  • Smaller meals, avoid lying down postprandially
• Step 2: H. pylori testing
  • If positive:
    • Treat with triple therapy: clarithromycin + amoxicillin + PPI (7 days)
    • Review after 4 weeks
      • If symptoms resolve → no further action
      • If symptoms persist → Carbon-13 urea breath test
        • If positive → re-treat
        • If negative → refer for OGD
  • If negative:
    • Empirical PPI trial for 4 weeks
      • If symptoms improve → no further action
      • If symptoms persist → refer for upper GI endoscopy

Investigations

• OGD (oesophagogastroduodenoscopy) – first-line investigation
• FBC – to assess for anaemia
• CXR – if aspiration is suspected
• Barium swallow – useful in oropharyngeal dysphagia or when OGD is non-diagnostic
• Manometry – for suspected motility disorders (e.g. achalasia)

Complications

• Aspiration pneumonia
• Malnutrition and weight loss
• Oesophageal perforation – due to stricture or instrumentation
• Oesophageal cancer – if dysphagia is progressive and associated with red flags
• Benign strictures – due to chronic reflux or caustic ingestion
• Barrett’s oesophagus – secondary to chronic GORD
• Anaemia – from chronic blood loss

Management

By Cause:

• Oesophageal cancer:
  • Surgical resection
  • Chemotherapy and/or radiotherapy
  • Palliative stenting if inoperable
• GORD / reflux strictures:
  • Lifestyle advice (weight loss, smoking cessation, avoid trigger foods)
  • PPIs (first-line)
  • Endoscopic dilation if stricture present
• Achalasia:
  • Pneumatic dilation
  • Botox injection
  • Heller’s myotomy (with fundoplication)
• Zenker’s diverticulum:
  • Surgical management (e.g. cricopharyngeal myotomy)
• H. pylori–associated dyspepsia:
  • Triple therapy: clarithromycin + amoxicillin + PPI

Supportive and Adjunctive Measures:

• Nutritional support:

  • NG or PEG feeding in severe cases
  • Referral to dietitian for long-term planning

• Endoscopic intervention:

  • Dilation for strictures
  • Stenting for malignant obstruction
  • Foreign body removal, if required

• Ongoing surveillance:

  • Regular OGD for Barrett’s oesophagus or chronic dysphagia