Difficulty Swallowing
Author – Bharneedharan Surendaran Editor – Dr James Mackintosh
Last updated 25/07/24
Table of Contents
Introduction
Difficulty Swallowing can be categorised into three sub groups as described by patients:
Dysphagia; Odynophagia; Globus.
The definition of dysphagia is difficulty in swallowing. However dysphagia can be further broken down in having difficulty swallowing solids or liquids or both and by the position where swallowing becomes difficult.
Odynophagia is painful swallowing and can make it difficult to swallow.
Globus is the sensation of feeling a lump in your throat but the lump does not exist. This condition is benign.
In this article we will explore how to take a focused history on dysphagia.
Structural and Functional Causes of Dysphagia
Causes of Dysphagia can be broken down into:
- ‘Structural’ – refers to a physical obstruction such as a mass or cancer or stricture causing the dysphagia.
- ‘Functional’ – means there are no physical abnormalities with swallowing but the patient cannot initiate, coordinate or complete the process of swallowing. This is often caused by a neurological condition.
Below is a list of some structural and functional causes of Dysphagia further broken into Upper vs Lower Dysphagia:
| Cause | Functional | Structural | ||
|---|---|---|---|---|
Upper Dysphagia | Luminal | Mural | Extrinsic | |
Stroke | Cancer | |||
Parkinson's Disease | Pharyngeal Pouch | |||
Myasthenia Gravis | ||||
Multiple Sclerosis | ||||
Motor Neurone Disease (Bulbar) | ||||
Myotonic Dystrophy | ||||
Lower Dysphagia | Achalasia | Foreign Body | Cancer | Mediastinal Mass |
Chaga's Disease | Stricture | Retrosternal Goitre | ||
Diffuse Oesophageal Spasm | Plummer-Vinson Syndrome | Bronchial Carcinoma | ||
CREST syndrome | Thoracic Aortic Aneurysm | |||
Pericardial Effusion | ||||
Presenting Complaint
Try to expand on the presenting complaint by asking the following questions:
Site
- Where is the food actually getting stuck?
- Upper i.e. the mouth or Lower towards their stomach in their oesophagus.
- Differentials for Upper dysphagia are Cancer, Pharyngeal Pouch, Stroke, Motor Neurone Disease and Multiple Sclerosis.
- Differentials for Lower dysphagia are Achalasia, GORD, Cancer, Oesophageal Strictures and Mediastinal masses
Onset
- Has the dysphagia come on suddenly or has it slowly gotten progressively worse?
- The main differential we want to keep in mind for sudden dysphagia is Cancer until proven otherwise.
- Progressive dysphagia is highly suggestive of a stricture (benign or malignant) but can also be seen in Achalasia, MND, and Myasthenia Gravis.
Timing
- Consider the Duration of symptoms and if the symptoms are constant or intermittent?
- Intermittent dysphagia typically occurs in Motility Disorders like Achalasia, Diffuse Esophageal Spasms and CREST syndrome.
- Constant dysphagia typically occurs in cancer and advanced motility disorders.
Associated Symptoms
- We can ask about the FLAWS symptoms (fatigue, lethargy, anorexia, weight loss and night sweats) to screen for cancer.
- We can ask the patient if they had any weakness or numbness, any fits, faints or funny turns and any changes in hearing, vision and balance and motor function to screen for neurological conditions causing their dysphagia.
- Reflux of food contents and any nausea and vomiting?
- Any gurgling
Other Useful Questions
- We can ask patients if they use NSAIDs, have a history of reflux or history of peptic ulcer disease to screen for peptic ulcer disease.
- Does anything make symptoms better or worse?
- Is the dysphagia for liquids, solids or both or neither of them?
Common Causes of Dysphagia
When a patient presents with dysphagia, we always want to rule out upper GI malignancy and neurological causes because these are the most common and most serious for the patient. Below are some of the common causes:
| Differentials | History |
|---|---|
Upper GI Cancer | Always think of B Symptoms using the acronym of FLAWS (Fever, lethargy anorexia weight loss and night sweats).
Also in any patient that you are worried about GI malignancy use the acronym ALARMS55 (Anaemia symptoms, lethargy, anorexia, recent onset, masses, swallowing changes and over 55). Always check for any changes in bowel habits and ask about black tarry stools (melaena). Check for alcohol and smoking history and family history of GI malignancy |
Stroke | Ask patient if they had any sudden neurological deficiencies (weakness or numbness and any fits, faints, funny turns and changes in hearing and vision) and
Screen for cardiovascular risk factors ( Smoking and alcohol history and high blood pressure and cholesterol and AF). Screen for family history of stroke and MI. |
Achalasia | Dysphagia that slowly progresses from solids to liquids.
A typical patient would be young and have no neurological symptoms and no risk factors for GI cancer or any other neurological conditions. Some patients will have a previous history of Chagas disease (very rare parasitic infection from South America). |
GORD | The patient would present with heartburn which is worse on lying down and relieved by antacids and consumption of dairy products. The patient can also complain of a metallic taste in their mouth due to the acidic contents reflux into their mouth. Patients with GORD are more at risk of oesophagitis, esophageal cancer and peptic ulcer disease. |
Tonsilitis | Tonsillitis typically occurs in younger patients. Patient present with a sore throat, feeling feverish and under the weather. Patients report difficulties in swallowing due to enlarged tonsils blocking food passage or inflamed tonsils causing painful swallowing. |
Pharyngeal Pouch | Pharyngeal pouches typically occur in elderly male patients. The patients complain about having bad breath after they have eaten and choking on their food. Their symptoms would progressively get worse over years. On examination they may have a neck swelling that gurgles on palpation when swallowing in the posterior triangle of the neck. |
Peptic Ulcer Disease | A typical patient would be a middle aged man who has is overweight, has a high alcohol consumption, a sedentary lifestyle and smoking history.They often present with epigastric pain. If the pain worsens after food it is more likely a gastric ulcer and if it improves it is more likely a duodenal ulcer. NSAID use can predispose patients to ulcers, worsen symptoms and cause ulcer perforation. |
Background
Past Medical History
- GORD – reflux of gastric contents can cause irritation of the oesophagus and make it painful to swallow and reduce the ability to swallow.
- Peptic ulcers can cause gastric outlet obstruction leading to dysphagia.
- Gastrointestinal surgery, GORD and Berrett’s oesophagus are risk factors for developing oesophageal cancer
- Neuromuscular disease affects the muscles used in swallowing e.g. Motor Neurone Disease and Parkinson’s
- Cardiovascular and cerebrovascular disease history are risk factors for strokes.
- Recent History of gastroenteritis preceding the dysphagia with other neurological signs can be suggestive of Guillain-Barre syndrome
- Rheumatological Disease – CREST Syndrome effects oesophageal motility that can affect swallow
Drug History
- Calcium-Channel Blockers and Nitrates relax smooth muscles and can worsen reflux.
- NSAIDs, Steroids and Bisphosphonates will predispose patients to peptic ulceration and reflux.
Social History
- Alcohol consumption and Smoking increase the risk of oesophageal malignancy
- Travel History – South America for Chagas Disease causing achalasia
- Diet – Changes in appetite can be a red flag symptom for malignancy
- If their symptoms worsen when consuming fried food, fast food, fatty and heavy meals could tell us that it could be reflux or peptic ulcer disease.
- Check with the patient if milk and dairy products improve their symptoms as this is suggestive of heartburn from reflux and peptic ulcer disease.
Family History
- Oesophageal Carcinoma
- Peptic ulcer disease and Gastrinoma
- Neuromuscular Disease
- Oxford Clinical Cases in Medicine and Surgery
- Dysphagia Oxford Medical Education:https://oxfordmedicaleducation.com/gastroenterology/dysphagia/
- Passmedicine Extended Textbook: https://passmedicine.com/