Ep 96 – Dysphagia

Dysphagia refers to difficulty swallowing. It can occur at any age and may be caused by various conditions, including neurological disorders, muscular disorders, structural abnormalities, or even psychological factors. Dysphagia can range from mild to severe, and it can lead to complications such as malnutrition, dehydration and aspiration pneumonia if not properly managed. The treatment for dysphagia depends on the underlying cause and may include dietary modifications, swallowing therapy, medication or surgery. In this episode, Dr Roger Henderson takes an overview look at the causes, assessment, investigations and treatments of dysphagia, along with a reminder of oesophageal cancer, its treatment and prognosis.

Key references

1. Azer SA, et al. 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
2. NICE. Interventional procedures guidance. Transcutaneous neuromuscular electrical stimulation for oropharyngeal dysphagia in adults (IPG634). 19 December 2018.
3. Charous SJ. Assessment of dysphagia. BMJ Best Practice. 30 August 2023.
4. Park H. Gut Liver. 2014;8(6):590-7. doi: 10.5009/gnl14081.
5. Jones R, et al. BMJ. 2007;334(7602):1040. doi: 10.1136/bmj.39171.637106.AE.

Key take-home points

• Dysphagia is difficulty in swallowing, associated with swallowing a liquid or solid bolus. It is usually associated with oesophageal or pharyngeal disease. If not associated with swallowing it is called globus hystericus, while painful swallowing is known as odynophagia.
• The most common oesophageal lesions are inflammatory strictures from tumours or reflux. A long history of heartburn increases inflammatory stricture risk.
• Eosinophilic oesophagitis appears to affect as many people as Crohn’s disease.
• Progressive and rapid worsening of dysphagia should suggest malignancy, especially if associated weight loss is present – particularly in patients aged 65 or over.
• There are multiple possible causes of dysphagia, including obstructive and neurological causes.
• Taking a careful history is vital as approximately 80% of oesophageal dysphagia cases can be diagnosed by history alone. Ask the patient to describe the symptoms in their own words and watch for terms such as “food sticking”, “chest pain”, “hurts to swallow” or pointing to where food sticks. Multiple symptoms increase the chances that an organic cause is present.
• Investigations include blood tests, barium swallow and endoscopy, and laryngoscopy if a pharyngeal cause is suspected. If a lesion is found (such as a tumour), magnetic resonance imaging scanning may then occur, as may endoscopic ultrasonography.
• If there are any concerns about malignancy causing dysphagia, a 2-week rule referral is mandatory.
• For neurological causes, early speech and language therapy assessment is helpful.
• In eosinophilic oesophagitis, dietary changes, steroids, leukotriene antagonists and dilation are all possible treatments. Transcutaneous neuromuscular electrical stimulation can be used to treat oropharyngeal dysphagia.
• Surgical options depend on the cause, such as endoscopic dilation for strictures with or without stenting, or resection in early oesophageal cancer.
• Oesophageal cancer often presents late – 75% of the gullet circumference is often involved before “food sticking” occurs as a symptom. This means that overall prognosis is poor.
• Oesophageal cancer survival rates depend on staging.