EN4.37 | Dysphagia — Summary & Reflection

KEY TAKEAWAYS

Dysphagia is difficulty swallowing — a symptom that demands systematic clinical reasoning to avoid missing malignancy. The critical first question is whether the patient has solid-only dysphagia (suggesting mechanical obstruction — carcinoma, peptic stricture, Schatzki ring, web, pouch) or dysphagia to both solids and liquids from the outset (suggesting a motility disorder — achalasia, diffuse oesophageal spasm, neurological disease). Progressive solid dysphagia with weight loss in a patient over 40 is a malignancy alarm symptom requiring urgent UGI endoscopy and biopsy. Key causes: carcinoma of the hypopharynx (referred otalgia, hoarseness, cervical nodes); carcinoma of the oesophagus (SCC upper/mid-third; adenocarcinoma lower-third on Barrett's); achalasia (diagnosed by manometry, treated by balloon dilatation or Heller's myotomy); pharyngeal pouch (elderly patient, regurgitation of undigested food, Boyce's sign); Plummer-Vinson syndrome (postcricoid web + iron-deficiency anaemia + dysphagia in middle-aged women — premalignant, requires annual surveillance). Investigations: barium swallow for functional overview; UGI endoscopy for tissue diagnosis; manometry for motility disorders.

REFLECT

Think about the last time you had difficulty swallowing something that 'went down the wrong way.' How does your brief experience of coughing and chest discomfort illuminate what patients with chronic dysphagia live with daily? Now consider: if a patient tells you 'food gets stuck in my chest and I've lost some weight,' what is going through your mind in the first 60 seconds of that consultation? Which two questions would you ask first, and why? Reflect on how the solid-vs-liquid distinction functions as a diagnostic shortcut — and consider its limits: can you think of a condition where this rule might be misleading?