Dysphagia 

1. Definition

Dysphagia = Difficulty in swallowing

It must be differentiated from:

• Odynophagia → painful swallowing
• Globus sensation → lump in throat without true dysphagia
• Anorexia / early satiety

2. Physiology of Swallowing 

Swallowing has 3 phases:

3. Classification 

A. Oropharyngeal Dysphagia (Transfer Dysphagia)

Difficulty initiating swallow.

Clues:

• Coughing immediately
• Nasal regurgitation
• Choking
• Aspiration pneumonia
• Voice change
• Neurological disease

Causes

—> Neurological

• Stroke
• Parkinson’s disease
• Motor neuron disease
• Myasthenia gravis
• Multiple sclerosis
• Bulbar palsy

—> Structural

• Pharyngeal pouch (Zenker’s diverticulum)
• Tumour
• Post-radiotherapy fibrosis

Zenker’s Diverticulum

• Regurgitation of undigested food
• Halitosis
• Gurgling in neck

B. Oesophageal Dysphagia

Food gets stuck after swallowing.

Step 1: Solids vs Liquids?

4. Structural Causes

1. Oesophageal Carcinoma

4

• Progressive dysphagia
• Weight loss
• Age > 55
• Iron deficiency anaemia

Risk factors:

• Smoking
• Alcohol
• Barrett’s oesophagus

Types:

• Squamous cell carcinoma (upper)
• Adenocarcinoma (lower)

2. Peptic Stricture

Due to chronic GERD.

• Long history reflux
• Dysphagia to solids

3. Schatzki Ring

• Intermittent solid dysphagia
• Food impaction episodes

5. Motility Disorders 

1. Achalasia

Failure of LES relaxation.

• Dysphagia solids + liquids
• Regurgitation
• No weight loss (early)
• Young patient

Investigation:

Gold standard → Manometry
Barium → Bird beak
Endoscopy → Rule out cancer

2. Diffuse Oesophageal Spasm

• Corkscrew oesophagus (barium)
• Intermittent dysphagia + chest pain

3. Systemic Causes

• Systemic sclerosis → hypotensive LES
• Diabetes mellitus → autonomic neuropathy

6. Eosinophilic Oesophagitis 

Clues:

• Young male
• Atopy
• Food bolus impaction
• Ringed oesophagus

Diagnosis:

15 eosinophils per HPF

Treatment:

• PPI
• Topical steroids
• Elimination diet

7. Dysphagia Algorithm 

Step 1: Oropharyngeal vs Oesophageal?

If aspiration → neurological workup.

Step 2: Progressive?

YES → Endoscopy urgently (2-week wait in UK)

Step 3: Solids first?

YES → Structural

Step 4: Solids + liquids from beginning?

→ Motility → Manometry

8. Investigations

9. Alarm Features 

• Age > 55
• Weight loss
• Anaemia
• Persistent vomiting
• Haematemesis
• Progressive symptoms

→ Urgent endoscopy

10. Dysphagia in Specific Diseases 

11. Management 

Structural

• Cancer → Surgery ± chemo
• Stricture → Dilatation
• Ring → Dilatation

Motility

• Achalasia → Pneumatic dilation / POEM / Heller myotomy
• Spasm → CCB / nitrates

Oropharyngeal

• Swallow rehab
• NG/PEG feeding
• Treat underlying cause

12. opd Tips

If patient says:

• “Food sticks after swallowing” → oesophageal
• “I choke immediately” → oropharyngeal
• “Liquids worse” → motility
• “Solids worse” → structural