That’s Tough to Swallow!

How do we go about exploring the world of dysphagia? One start was to review a case of a 49 year old gentleman with a history of polysubstance abuse (heroin, alcohol) who presented with several days of dysphagia with more difficulty with solids. Further investigation revealed that he had no trouble initiating his swallowing, but that instead food feels as if it “gets stuck” with intermittent episodes in the past few months.  Additionally, he had associated epigastric pain with early satiety and a reported 20-70 lb weight loss over the course of the past year.

Discussed were the different approaches to working up dysphagia, which can be categorized into two separate entities of oropharyngeal and esophageal etiologies).  Furthermore, characteristics of the type of substances causing difficulty further facilitated our reasoning:

* Difficulty swallowing solids suggests more of a mechanical/structural etiology whereas both solids and liquids suggest a motility issue.

*Clinicians should also be cognizant of the controversy that occurs involving the best initial test that one should ensue for diagnosis:  Barium swallow has been the standard, although if structural etiology is concerned, EGD may initially be the best way to go.  (Review the most recent guidelines from the World Gastroenterology Organization 2007)

*Lastly, there was a brief review of the different types of esophageal CA (patient found to have exophytic mass with patholgy pending):

-Squamous Cell seen more in AA pts, mass located in thoracic region, alcohol and smoking as risk factors while

–Adenocarcinoma seen more in Caucasians, mass more distally located, GERD, obesity and Barrett’s being risk factors.

BMJ 2003 has a nice review and schematics on the investigation and management of chronic dysphagia found here.