Regarding Clinical Presentations Of Dysphagia

Regarding Dysphagia Select a diagnosis from the list below for the given clinical scenarios:

A. Pharyngeal pouch
B. Achalasia
C. Kaposi's sarcoma
D. Systemic sclerosis
E. Oesophageal cancer
F. Myasthenia gravis
G. Oesophagitis
H. Motor neuron disease
I. Oesophageal candidiasis
J. Plummer-Vinson syndrome

1. An 40-year-old man presents with dysphagia. He reports being reasonably well in himself other than an occasional cough. The dysphagia occurs with both liquids and solids. Clinical examination is normal.

Answer: Achalasia ( Patients like this should be referred to exclude a carcinoma. Achalasia typically presents between the ages of 25-40 years.)

2. A 55-year-old woman presents with swallowing difficulties for the past 5 weeks. She has also noticed some double vision.

Answer: Myasthenia gravis

3. A 42-year-old haemophiliac who is known to be HIV positive presents with pain on swallowing for the past week. He has been generally unwell for the past 3 months with diarrhoea and weight loss.

Answer: Oesophageal candidiasis
( Unfortunately many haemophiliacs contracted HIV and hepatitis C in the 1980's from blood transfusions. Immunocompromised patients are prone to oesophageal candidiasis. This patient requires an urgent endoscopy to confirm the diagnosis.)

Discussion:


Dysphagia: 
Characteristic exam question features for conditions causing dysphagia is given below;

1. Oesophageal cancer: Dysphagia may be associated with weight loss, anorexia or vomiting during eating Past history may include Barrett's oesophagus, GERD, excessive smoking or alcohol use.

2. Oesophagitis: May be history of heartburn,  Odynophagia but no weight loss and systemically well

3. Oesophageal candidiasis: There may be a history of HIV or other risk factors such as steroid inhaler use

4. Achalasia: Dysphagia of both liquids and solids from the start , Heartburn , Regurgitation of food - which may lead to cough, aspiration pneumonia etc

5. Pharyngeal pouch: More common in older men , Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles. Usually not seen but if large then a midline lump in the neck that gurgles on palpation. Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen.

6. Systemic sclerosis: Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia . As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased. This contrasts to achalasia where the LES pressure is increased.

7. Myasthenia gravis: Other symptoms may include extraocular muscle weakness or ptosis. Dysphagia with liquids as well as solids.

8. Globus hystericus: May be history of anxiety. Symptoms are often intermittent and relieved by swallowing, Usually painless - the presence of pain should warrant further investigation for organic causes.