Dysphagia

When a patient says ‘swallowing difficulty’, they could mean: • Dysphagia: difficulty swallowing. If they really mean dysphagia, try to understand when/where exactly it feels as though the food ‘gets stuck’. Those with high dysphagia (oropharyngeal and upper oesophageal) describe difficulty initiating a swallow or immediately upon swallowing. Those with low dysphagia (lower oesophageal) feel the food getting stuck a few seconds after swallowing. • Odynophagia: painful swallowing. Odynophagia may be due to malignancy, but is more commonly a feature of infection such as candidiasis. • Globus: the common sensation of having a lump in the throat without true dysphagia. Globus is very common and its aetiology is poorly understood—however, only a small proportion of affected patients will seek medical help and it is an entirely benign condition. Broadly speaking, high dysphagia is more likely to be due to generalized/systemic neuromuscular disease, whereas low dysphagia is more likely to be due to a local obstructing lesion. New-onset dysphagia in middle-aged to elderly patients is carcinoma until proven otherwise. • What is the duration of the symptoms? This is a key question: a food bolus stuck in the oesophagus will typically appear immediately during a meal; cancer typically presents with a short history of days to weeks (not because the cancer has appeared in such a short space of time, but because it has reached a size where symptoms rapidly become apparent), whereas chronic motility disorders such as achalasia present with symptoms lasting months to years. • Is the dysphagia progressive or intermittent? Progressive dysphagia is highly suggestive of a stricture (benign or malignant), whereas intermittent symptoms are more characteristic of motility disorders. • Is the dysphagia to solids, fluids, or both? If the patient is able to swallow fluid as normal but has difficulty with solid food items (which feel as if they are sticking) this points towards a mechanical obstruction, i.e. a stricture (benign or malignant). Of course, as the stricture becomes more severe, then the dysphagia may start to involve fluids as well.