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2. What are the two main divisions of the causes of dysphagia?
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Correct answer:
Local causes and general causes.
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3. How are the local causes of obstruction of any tube of the body subdivided?
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Correct answer:
Those in the lumen; those in the wall; and those outside the wall.
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4. What are the local causes of dysphagia?
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Correct answer:
(1) In the lumen: foreign body.
(2) In the wall: congenital atresia; inflammatory stricture - secondary to reflux oesophagitis; caustic stricture; achalasia; Plummer-Vinson syndrome with oesophageal web; pharyngeal pouch; Schatzki ring; tumour of oesophagus or cardia; systemic sclerosis (scleroderma).
(3) Outside the wall: bronchial carcinoma; retrosternal goitre; aneurysm of the thoracic aorta; node - pressure from an enlarged lymph node.
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5. What are the intraluminal causes of dysphagia?
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Correct answer:
Foreign body.
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6. What are the causes of dysphagia within the oesophagus wall?
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Correct answer:
(1) Congenital atresia. (2) Inflammatory stricture – secondary to reflux oesophagitis. (3) Caustic stricture. (4) Achalasia. (5) Plummer–Vinson syndrome with oesophageal web. (6) Pharyngeal pouch. (7) Tumour of the oesophagus or cardia (8) systemic sclerosis (scleroderma).
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7. What are the causes of dysphagia originating outside the oesophagus?
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Correct answer:
(1) Bronchial carcinoma. (2) Retrosternal goitre. (3) Aortic aneurysm in the thorax. (4) Node pressure from malignancy.
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8. What are the general causes of dysphagia?
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Correct answer:
(1) Bulbar palsy. (2) Hysteria. (3) Bulbar poliomyelitis. (4) Myasthenia gravis. (5) Diphtheria.
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9. What do you need to elicit from the history of dysphagia?
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Correct answer:
The subjective site of obstruction is not always exact; the patient often merely points vaguely to behind the sternum. The diagnosis may be given by a history of swallowed caustic in the past. A previous story of reflux oesophagitis suggests a peptic stricture. Patients with achalasia tend to be young and the history is often long, usually without loss of weight. Malignant stricture has a short history, occurs in elderly people and is associated with severe weight loss.
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10. What should you look for on examination of a patient with dysphagia?
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Correct answer:
Often this is negative, but search is made for clinical evidence of Plummer–Vinson syndrome (a smooth tongue, anaemia and koilonychia); secondary nodes from a carcinoma of the oesophagus may be felt in the neck and supraclavicular fossae; and the upper abdomen is carefully palpated, as a carcinoma of the cardia is a common cause of dysphagia in elderly patients and indeed is more common in this country than carcinoma of the oesophagus.
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11. What special investigations would you use to investigate dysphagia?
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Correct answer:
Barium swallow and fibreoptic oesophagoscopy (which enables biopsy).
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12. Why might a barium swallow be used to investigate dysphagia?
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Correct answer:
Barium swallow, with cine-radiography, may demonstrate the characteristic appearances of a cervical web, extrinsic compression and the dilated oesophagus of achalasia.
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13. What are the reasons for people swallowing foreign bodies?
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Correct answer:
Foreign bodies are swallowed either accidentally, usually by children, or deliberately by mentally disturbed people, prison inmates and circus sideshow performers. A recent phenomenon is a ‘body-packer’, a smuggler who swallows condoms packed with cocaine or heroin. These may present with bowel obstruction, or may rupture, producing coma or death from absorption of the drug.
