Dysphagia is defined as difficulty in swallowing. It is usually associated either with pharyngeal or oesophageal disease.[1, 2] There is a spectrum of possible aetiologies (see links in table under Aetiology, below), from self-limiting illness (eg, tonsillitis) to carcinoma. It may occur with odynophagia - painful swallowing.
- As well as the feeling of food sticking in the gullet, patients with oesophageal disease may have other symptoms. These range from discomfort to severe pain, with the patient nearly always unable to locate the obstruction accurately.
- Regurgitation, vomiting, coughing and choking are common.
- Men with new onset of alarm symptoms (loss of weight with worsening dysphagia) have an increased likelihood of a diagnosis of cancer, especially in those aged over 65.A positive predictive value of 9.0% has been found in this age group.
- The most common lesions within the oesophagus are inflammatory strictures from reflux or tumours.
- A long history of heartburn is usually associated with an inflammatory stricture.
- In Westernised countries, eosinophilic oesophagitis is thought to affect between 40 and 55 per 100,0000 population - similar to the numbers affected by Crohn's disease.
- Idiopathic achalasia presents with dysphagia for solids and also regurgitation of a bland-tasting material that has never entered the stomach. It occurs in 1-2/100,000, most commonly seen in mid-adult life, and is caused by impaired neural control of the distal oesophagus.
- FBC and erythrocyte sedimentation rate (ESR) should be taken.
- Barium swallow and/or endoscopy with biopsy should usually be performed.
- MRI scanning may also be required before any surgery is considered - eg, if there is oesophageal carcinoma.
- Endoscopic ultrasonography can assist with staging in oesophageal carcinoma.
- Videofluoroscopy is the radiological investigation of choice when 'difficulty swallowing' rather than 'food sticking' is the presenting symptom and/or aspiration is suspected.
- Oesophageal motility studies (require swallowing a catheter containing a pressure transducer) are useful when oesophageal spasm is suspected.
The patient may need to chew well or liquidise food.
There is insufficient evidence currently to support the efficacy of dietary modification, swallowing manoeuvres, surgical interventions or enteral feeding for the treatment of chronic neuromuscular conditions. Patients with neurological problems (eg cerebrovascular injury) may benefit from an early Speech and Language Therapy assessment.[7, 8]
Eosinophilic oesophagitis may be treated with dietary modification, topical steroids, leukotriene antagonists and other drugs, and endoscopic dilation.
Definitive treatment depends on cause:
- Strictures may be managed with endoscopic dilation (either using bougies or inflatable balloons).
- If oesophageal carcinoma is diagnosed, staging will dictate whether curative surgery (for example, oesophagectomy) and chemotherapy are appropriate.
- Overall, the five-year survival of patients with oesophageal carcinoma ranges from 15-25%.
- In oesophageal carcinoma, palliative relief of dysphagia can be achieved with:
- Repeated dilatation
- Stent replacement
- Laser photocoagulation
- Injection of sclerosants
- Brachytherapy can be a useful alternative or adjunct.
- Surgical myotomy and endoscopic injection of the sphincter with botulinum toxin are occasionally used for some aetiologies.
Further reading and references
Transcutaneous neuromuscular electrical stimulation for oropharyngeal dysphagia; NICE Interventional Procedure Guidance, May 2014
Acute stroke pathway; NICE, July 2014
Dent J, Holloway RH and Neale G; Oxford Textbook of Medicine, 4th Edition
Owen W; ABC of the upper gastrointestinal tract. Dysphagia. BMJ. 2001 Oct 13323(7317):850-3.
Jones R, Latinovic R, Charlton J, et al; Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database. BMJ. 2007 May 19334(7602):1040. Epub 2007 May 10.
Park H; An Overview of Eosinophilic Esophagitis. Gut Liver. 2014 Nov8(6):590-597. Epub 2014 Nov 15.
Referral for suspected cancer; NICE Clinical Guideline (2005)
Hill M, Hughes T, Milford C; Treatment for swallowing difficulties (dysphagia) in chronic muscle disease. Cochrane Database Syst Rev. 2004(2):CD004303.
Management of patients with stroke: Identification and management of dysphagia; Scottish Intercollegiate Guidelines Network - SIGN (June 2010)
Geeganage C, Beavan J, Ellender S, et al; Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev. 2012 Oct 1710:CD000323. doi: 10.1002/14651858.CD000323.pub2.
Pennathur A, Gibson MK, Jobe BA, et al; Oesophageal carcinoma. Lancet. 2013 Feb 2381(9864):400-12. doi: 10.1016/S0140-6736(12)60643-6.
Sreedharan A, Harris K, Crellin A, et al; Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev. 2009 Oct 7(4):CD005048.
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