Chapter 48

### Introduction

We swallow approximately 1200 times daily, largely subconsciously. While we take the fundamental function for granted, disordered swallowing can be a devastating condition, with substantial morbidity for those affected.

Ian Cook 1996

Dysphagia is difficulty in swallowing. It is a common problem affecting up to 22% of patients in the general practice setting.1 It is usually associated with a sensation of hold-up of the swallowed bolus and is sometimes accompanied by pain.

Its origin is considered as either oropharyngeal or oesophageal. Oropharyngeal dysphagia is usually related to neuromuscular dysfunction and is commonly caused by stroke. Oesophageal dysphagia is usually due to motor disorders, such as achalasia or diffuse oesophageal spasm, and to peptic oesophageal strictures often secondary to reflux. In this type of dysphagia there is a sensation of a hold-up, which may be experienced in either the cervical or retrosternal region.1 Causes are usually classified as functional, mechanical and neurological (see Table 48.1).

Table 48.1

Causes of dysphagia

Dysphagia must not be confused with globus sensation, which is the sensation of the constant ‘lump in the throat’ although there is no actual difficulty swallowing food. If dysphagia is progressive or prolonged then urgent attention is necessary.

There are only a few common causes of dysphagia and these are usually readily diagnosed on the history and two or three investigations. A careful history is very important, including a drug history and psychosocial factors.

### Diagnostic guidelines

• Any disease or abnormality affecting the tongue, pharynx or oesophagus can cause dysphagia.

• Patients experience a sensation of obstruction at a definite level with swallowing food or water; hence, it is convenient to subdivide dysphagia into oropharyngeal and oesophageal.

• Pain from the oropharynx is localised to the neck.

• Pain from the oesophagus is usually felt over the T2–6 area of the chest.

• Oropharyngeal causes: difficulty initiating swallowing; food sticks at the suprasternal notch level; regurgitation; aspiration.

• Oesophageal causes: food sticks to mid to lower sternal level; pain on swallowing solid foods, especially meat, potatoes and bread, and then eventually liquids.

• A pharyngeal pouch usually causes regurgitation of undigested food and gurgling may be audible over the side of the neck.

• Neurological disorders typically result in difficulty swallowing or coughing or choking due to food spillover, especially with liquids.

• Dysphagia for solids only indicates a structural lesion, such as a stricture or tumour.

• Dysphagia for liquids and solids is typical of an oesophageal motility disorder, namely achalasia.2

• GORD tends to exclude achalasia.

• Gastroenterologists claim that the big three common causes referred to them are benign peptic ...

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