3. History:-
1. Age.
2. Sex.
3. Mode of onset & progress.
4. Regurgitation.
5. Pain.
6. Vomitus.
7. Coughing.
8.Loss of weight.
9.Past history.
4. History:-
1. Age:-
In children:- Dysphagia may be caused by
impaction of a foreign body, paralysis of soft palate.
(due to diphtheria) & acute retropharyngeal abscess.
In young girls:- hysterical spasm may be seen.
In middle age:- the common causes of dysphagia
are benign stricture (may occur at any age of adult
life.),achalasias (30 to 40 years) and paterson-
Kelly(Plummer-Vinson) syndrome.
In old age:- Carcinoma of Oesophagus is a
disease of old age(50 to 70 years).
5. History:-
2. Sex:-
In Female:- Paterson-Kelly syndrome
(sideropenic dysphagia) occurs almost
exclusively in females nearing menopause
(over 40 years of age).
In male:- Carcinoma of oesophagus mainly
affects men.
Common:- Achalasia occurs in both sexes
though women may dominate.
6. History:-
3. Mode of onset & progress:-
A sudden onset may suggest foreign body
obstruction or acute oesophagitis.
A comparatively short history of difficulty in
swallowing ( a few month duration) in the elderly
suggests carcinoma of oesophagus.
A slow onset with a long history obtained in benign
stricture, achalasia, pharyngeal pouch etc.
Progressively worsening dysphagia is typical of
carcinoma and stricture.
7. History:-
3. Mode of onset & progress:-
In case of spastic lesions (Paterson- Kelly
syndrome and Schatzki’s ring) there may be
period of remission.
Difficulty in swallowing first with solids and
subsequently with liquids points to mechanical
obstruction.
This is mainly seen in carcinoma of oesophagus.
In the latter condition the weight of the solid helps
in overcoming the spasm.
8. History:-
4. Regurgitation:-
This is often seen in achalasia, but may be
seen in sliding hiatus hernia with stooping
or straining.
Pharyngeal pouch may cause regurgitation.
In this case a lump in the neck may be
visible which may be emptied with pressure.
9. History:-
5. Pain:-
Typical pain along with dysphagia is only
complained of in reflux oesophagitis or in
corrosive stricture.
But majority of patients with dysphagia will
complain of some sort of discomfort at the site of
obstruction.
This type of pain is mainly felt just beneath the
sternum.
According to the site of obstruction this is felt
either behind the upper part of the sternum or
behind its lower part.
10. History:-
6. Vomitus:-
If present, should be examined noting the amount,
reaction (it is generally not acid in causes other
than reflux oesophagitis), odour and presence of
blood (carcinoma or oesophageal reflux or very
rarely in achalasia).
When the oesophagus has been marked by
dilatation the patient may complain of vomiting of
foul – smelling stagnated intraoesophageal
contents of 2 to 3 days old.
Post- prandial vomiting is also complained of in
para- oesophageal hernia.
This condition may cause haematemesis.
11. History:-
7. Coughing:-
Coughing is not a common symptom in this cases.
Persistent coughing is only come across due to
irritation by a mediastinal mass.
Coughing occurring immediately after feeds
indicates tracheo- oesophageal fistula.
Coughing, which occurs sometime after ingestion
of meals may be due to regurgitation of food in
case of cardiospasm or pharyngeal pouch.
12. History:-
8. Loss of weight:-
This is quite appreciable
and is common in achalasia
and malignant lesion
of the oesophagus.
The typical Barium
meal X-ray of a
pharyngeal pouch.
13. History:-
Past history:-
A history of radiation, instrumentation or
swallowing of corrosive such as concentrated acid
or alkali may be obtained in simple stricture of
oesophagus.
Past history of vagotomy indicates
perioesophagitis to be the cause of dysphagia.
Similarly previous history of hiatus hernia repair
indicates excessive tightness of the repair to be the
cause of dysphagia.
Diphtheria may result in dysphagia.
Symptoms of other bowel diseases may indicate a
rare entity – Crohn’s disease of oesophagus.
15. PHYSICAL EXAMINATION:-
General survey:-
Emaciation is usually in a case of dysphagia but is
much more prominent in case of achalasia and
malignant diseases.
Anaemia is very much evident in Paterson- Kelly
syndrome and carcinoma of oesophagus and in
reflux oesophagitis.
Radial pulses will be inequal on two sides in case of
aneurysm of the aorta.
Concave and spoon- shaped nail is peculiar of
Paterson- Kelly syndrome.
The tongue is also smooth, pale and devoid of
papillae in Paterson- Kelly syndrome.
16. PHYSICAL EXAMINATION:-
1.Examinarion of the Mouth and
Pharynx:-
Tonsils and fauces should be examined for
any lesion.
Test the mobility of the soft palate to
determine if it is paralysed or not.
The posterior wall of the pharynx is
examined to exclude retropharyngeal
abscess.
17. PHYSICAL EXAMINATION:-
2.Examination of the neck:-
An obvious swelling like enlarged thyroid or
lymph nodes may press upon the pharynx or
oesophagus to cause dysphagia.
A soft swelling which appears during meals just
above the left clavicle is the third stage of
pharyngeal pouch.
Pressure over such swelling will cause
regurgitation of food into the mouth.
‘Tracheal tugging’ is a sign of aneurism of the arch
of aorta.
18. PHYSICAL EXAMINATION:-
2. Examination of the neck:-
The clinician stands behind the patient and hold
the cricoid cartilage with a little upward traction.
The downward tug can be felt with each throb of
the aorta.
It must be remembered that if no relevant sign can
be elicited on examination of the neck one must
palpate the left supraclavicular fossa to exclude
presence of enlarged lymph nodes which may be
the only sign in case of carcinoma of oesophagus.
19. PHYSICAL EXAMINATION:-
3. The chest:-
This should be examined routinely but in majority
of cases there will be hardly any abnormality in a
case of dysphagia.
One may get pleural effusion in a late case of
oesophageal carcinoma.
Aspiration pneumonitis, which may cause lung
abscess, bronchiectasis, haemoptysis may be seen in
achalasia.
In this condition when the oesophagus is hugely
dilated dyspnoea may be complained of with
displacement of adjacent structures.
On careful examination one may detect intra-
thoracic hernia sac in case of paraoesophageal
hernia.
20. PHYSICAL EXAMINATION:-
4. The abdomen:-
Barring an abnormal mass due to infiltration of
oesophageal carcinoma to the upper end of the
stomach and enlarged liver due to metastasis in
carcinoma of the cardia, there will be hardly any
abnormality in a case of dysphagia.
21. PHYSICAL EXAMINATION:-
5. The spine:-
If Pott’s disease is suspected to cause
dysphagia due to its cold abscess
pressing on the pharynx or oesophagus
one should examine the cervical region
of the spine.
23. CAUSES OF DYSPHAGIA:-
1. In the mouth.
2. In the pharynx.
3. In the oesophagus.
Barium meal X-ray of benign
stricture of the oesophagus.
24. CAUSES OF DYSPHAGIA:-
1.In the mouth:-
Tonsillitis, quinsy (peritonsillar abscess),
certain varieties of stomatitis, carcinoma of
the tongue and paralysis of the soft palate
(due to diphtheria in children and bulbar
paralysis in adults).
25. CAUSES OF DYSPHAGIA:-
2. In the pharynx:-
I. In the lumen- impaction of a foreign body
(e.g. coin, tooth and denture).
II. In the wall- acute pharyngitis, malignant
growth, hysterical spasm, Paterson- Kelly
syndrome.
III. Out side the wall:- Retropharyngeal
abscess, enlarged cervical lymph node,
malignant thyroid etc.
26. CAUSES OF DYSPHAGIA:-
3.In the oesophagus:-
I. In the lumen- impaction of a foreign body.
II. In the wall- (a)Atresia of oesophagus;(b)Benign
stricture- may be due to reflux oesophagitis,
swallowed corrosives, tuberculosis,
scleroderma, radio therapy etc.;( c) Spasm-
Paterson Kelly syndrome, achalasia, webs and
rings, diffuse oesophageal spasm etc.;(d)
Diverticulum; (e) Neoplasm- mainly
malignant;(f) Nervous disorders- bulbar
paralysis, post-vagotomy;(g) Miscellaneous-
Crohn’s disease etc.
27. CAUSES OF DYSPHAGIA:-
3. In the oesophagus:-
III. Out side the wall- malignant or any large
thyroid swelling, retrosternal goitre,
pharyngeal diverticulum, aneurism of the
aorta, mediastinal growth, dysphagia
lusoria, perioesophagitis after vagotomy,
hiatus hernia particularly
paraoesophageal (type 2) and tight
oesophageal hiatus repair.
28. DIFFERENTIAL DIAGNOSIS:-
Atresia of oesophagus.
Paterson Kelly syndrome
(Plummer- Vinson syndrome).
Pharyngeal pouch.
Benign stricture.
Achalasia or Cardiospasm.
Barium meal X-ray
of a case of
carcinoma of the
oesophagus.
29. DIFFERENTIAL DIAGNOSIS:-
Diffuse oesophageal spasm.
Scleroderma.
Diverticula of oesophagus.
Webs and rings.
Carcinoma of oesophagus.
Barium meal X-ray of
a case of oesophageal
varix.
