Dysphagia Clinical Approach and Barium Findings
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Direct answer
Dysphagia is difficulty swallowing, and its approach first decides whether the problem lies in the oropharynx or the oesophagus, then whether it is mechanical or motor. Oropharyngeal dysphagia causes coughing and nasal regurgitation at the start of swallowing, while oesophageal dysphagia is felt as food sticking after it has passed the throat. Progressive dysphagia to solids in an older adult is a red flag for malignancy until proven otherwise.
What you must remember
- Oropharyngeal dysphagia: Trouble initiating the swallow, coughing, nasal regurgitation and aspiration; causes include stroke, bulbar palsy, myasthenia and Parkinson disease.
- Oesophageal dysphagia: A sensation of food sticking below the suprasternal notch; causes include strictures, rings, webs, tumours and achalasia.
- Solids before liquids: Suggests mechanical obstruction, such as a stricture or carcinoma.
- Solids and liquids equally: Suggests a motility disorder, such as achalasia or diffuse oesophageal spasm.
- Barium findings: Bird's beak in achalasia, apple-core in a malignant stricture, corkscrew in spasm and a web or ring as a filling defect.
- Red flags: Age over 50, weight loss, progressive dysphagia, haematemesis, anaemia, hoarseness and lymphadenopathy.
Two patients, two pathways
Two patients with dysphagia need different pathways, and the table separates them on the key clues.
| Feature | 64-year-old man | 30-year-old woman |
|---|---|---|
| Symptoms | Progressive dysphagia to solids for three months, with weight loss and anaemia | Dysphagia to both solids and liquids for two years, with food regurgitation, chest discomfort and stable weight |
| Barium swallow | Apple-core lesion in the distal oesophagus | Dilated oesophagus with a bird's beak narrowing at the lower end |
| Key step | Urgent endoscopy with biopsy, then CT and endoscopic ultrasound for staging | High-resolution manometry, showing incomplete lower oesophageal sphincter relaxation and absent peristalsis |
| Diagnosis | Adenocarcinoma | Achalasia |
| Management | Surgery, chemoradiation or palliation, depending on staging | Pneumatic dilatation, peroral endoscopic myotomy or surgical myotomy; Chagas disease considered in endemic regions |
The equal difficulty with liquids and solids points to a motility disorder, while progressive solid dysphagia with weight loss is a malignancy red flag that calls for urgent endoscopy rather than a trial of therapy. The exam expects you to reason from the solids-liquids pattern, the speed of progression and the barium image.
Where the exam tries to catch you
Dysphagia questions usually turn on a few clues.
- Trap: ignoring the solids-versus-liquids clue Correct: mechanical obstruction gives solids first, while achalasia gives liquids and solids from the outset, and examiners set vignettes that hinge on that difference.
- Trap: missing Plummer-Vinson syndrome Correct: an upper oesophageal web with iron deficiency anaemia and dysphagia carries a higher risk of post-cricoid carcinoma.
- Trap: treating Zenker's diverticulum as an oesophageal stricture Correct: a pharyngeal pouch causing regurgitation of undigested food, halitosis and gurgling is often mistaken for a stricture.
- Trap: reaching for endoscopy first in neurological dysphagia Correct: dysphagia with neurological disease is oropharyngeal until shown otherwise, and the investigation of choice there is a videofluoroscopic swallow study rather than endoscopy.
Frequently asked questions
Does dysphagia that starts with solids and progresses to liquids suggest oropharyngeal or oesophageal disease?
Dysphagia that starts with solids and progresses to liquids suggests mechanical oesophageal obstruction, such as a stricture or carcinoma. Oropharyngeal dysphagia more often causes coughing and nasal regurgitation from the start of swallowing.
Which barium swallow finding is characteristic of achalasia?
Achalasia shows a bird's beak narrowing at the lower oesophagus on barium swallow, with a dilated oesophagus above it. High-resolution manometry confirms the diagnosis, showing incomplete lower oesophageal sphincter relaxation and absent peristalsis.
What is the investigation of choice for oropharyngeal dysphagia?
Videofluoroscopic swallow study is the investigation of choice for oropharyngeal dysphagia, because it shows aspiration and pharyngeal transit in real time. Bedside swallow assessment is usually the first step before imaging.
Which red flags suggest oesophageal malignancy in dysphagia?
Progressive dysphagia to solids, weight loss, anaemia and age over 50 are red flags for oesophageal malignancy. These features call for urgent upper gastrointestinal endoscopy with biopsy rather than a trial of acid suppression.
What is a Plummer-Vinson web and what is it associated with?
A post-cricoid web in Plummer-Vinson syndrome causes upper oesophageal dysphagia, often with iron deficiency anaemia. The condition is associated with a higher risk of post-cricoid carcinoma, so iron replacement and surveillance are important.