24 HOW TO TREAT: DYSPHAGIA
24 HOW TO TREAT: DYSPHAGIA
22 AUGUST 2025 ausdoc. com. au hay fever. He denies any food allergies.
A chest X-ray is performed, which is normal. An endoscopy is performed, which demonstrates an impacted food bolus in the mid-oesophagus, with associated mucosal inflammation. The food bolus is retrieved and the endoscope can be passed into the stomach without resistance. The oesophageal mucosa is characterised by longitudinal furrows, concentric rings and white plaques. Biopsies are taken of the upper, mid- and lower oesophagus, which confirm a diagnosis of eosinophilic oesophagitis, as demonstrated by an eosinophil count of greater than 15 per high-power field.
David is started on budesonide orally disintegrating tablets 1mg bd. He returns for a repeat endoscopy after 12 weeks to confirm remission, with repeat biopsies confirming fewer than five eosinophils per high-power field. He continues on budesonide and is seen as an outpatient every 6-12 months for ongoing follow-up. He has no further episodes of food bolus obstruction.
Case study two
Michael is a 50-year-old mechanic who presents to his GP with dysphagia. Over a period of a few months, he has noted intermittent difficulty swallowing both solids and liquids, feeling as if they get stuck in his chest. He then usually has to regurgitate the food. There is no associated pain. He has reduced his oral intake as a result and has lost 5kg in the past six months. His past medical history is significant for hypertension, which is treated with perindopril.
A barium swallow is performed, which demonstrates a typical‘ bird’ s beak’ appearance with a dilated oesophagus and sharp tapering at the gastro-oesophageal junction. An endoscopy is subsequently performed, during which resistance to passage of the endoscope past the gastro-oesophageal junction is
How to Treat Quiz. noted, as well as a dilated and fluid-filled oesophagus proximal to this. No obstructive lesion is identified. A preliminary diagnosis of achalasia is made, which is subsequently confirmed on oesophageal manometry as type II. The risks and benefits of the various management strategies are discussed with Michael. He decides to proceed with pneumatic balloon dilation. However, his dysphagia recurs after three years.
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1. Which TWO statements regarding the epidemiology of dysphagia are correct? a Dysphagia is more common in the elderly. b Eosinophilic oesophagitis is more common in the older population. c Opioids are recognised as an important cause for oesophageal dysmotility and dysphagia. d Dysphagia rarely impacts on quality of life or psychosocial wellbeing.
2. Which THREE are risk factors for dysphagia? a Atopy. b Immunocompromise. c Cardiovascular disease. d Neurodegenerative disorders.
3. Which THREE form part of normal swallowing? a Elevation of the tongue and co-ordinated contraction of the pharyngeal muscles. b Presence of food or fluid bolus activates excitatory neurons and results in muscle contraction to propel the bolus distally. c Relaxation of the upper oesophageal sphincter along with co-ordinated peristaltic contraction and relaxation of circular and longitudinal muscles in the oesophagus.
d Relaxation of the lower oesophageal sphincter.
4. Which THREE are features of oropharyngeal dysphagia? a Cannot be caused by oesophageal pathology. b Associated with a delayed or absent swallow initiation. c The need for repetitive swallows to clear a bolus from the pharynx. d The onset of symptoms immediately on attempting to swallow.
5. Which THREE are features of globus? a A constant sensation of tightness or a foreign body sensation in the throat or neck. b Results from increased perception of, and hypervigilance to, sensations in the area— often without any bolus present. c Aggravated by meal consumption. d Often persistent and independent of swallowing.
6. Which TWO are red flags for malignancy? a Onset before age 50. b Anaemia. c Slowly developing dysphagia. d Weight loss.
7. Which THREE are the main tests performed to assess suspected oesophageal dysphagia? a Video barium swallow. b Flexible endoscopic evaluation of swallowing. c Endoscopy. d Oesophageal manometry +/- oesophageal reflux monitoring.
8. Which TWO statements regarding achalasia are correct? a The barium swallow demonstrates a‘ bird’ s beak’ appearance with a dilated oesophagus that tapers sharply distally. b The most efficacious treatment is pneumatic balloon dilation. c Management strategies target symptom minimisation and avoidance of nutritional deficits.
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Figure 9. Schatzki’ s ring on endoscopy.
DYSPHAGIA
Given his age and lack of significant comorbidities, he is referred for a POEM procedure. This is successful in resolving his dysphagia, but he develops postoperative reflux symptoms, which are adequately managed with a PPI.
Case study three
Susan, an 84-year-old retired musician, presents with dysphagia. She has been experiencing an increasing
d The gold-standard method for diagnosis is barium swallow.
9. Which THREE statements regarding dysphagia are correct? a Hypomotility of the oesophagus is more frequently seen in the elderly. b Benign oesophageal strictures are predominantly caused by gastro-oesophageal reflux disease. c Pharmacotherapy in eosinophil oesophagitis is primarily focused on topical steroid therapy with gut-specific orally disintegrating budesonide. d Patients with hypercontractile disorders of the oesophagus are typically asymptomatic.
10. Which THREE statements regarding dysphagia are correct? a Opioids equivalent to 20mg a day of morphine can typically induce oesophageal dysmotility. b A diagnosis of pharyngeal pouch is best made on endoscopy. c Patients with oesophageal cancer tend to present late in the disease process. d Standard treatment for a Schatzki’ s ring and oesophageal web involves dilatation and treatment of underlying reflux disease if present. difficulty swallowing towards the end of a solid meal and often regurgitates food about an hour after eating. She feels as if the food gets stuck at the back of her throat. Susan has lost 3kg in the past 12 months. Her past medical history is significant for rheumatoid arthritis, type 2 diabetes and congestive cardiac failure.
A speech pathology assessment with fibre-optic endoscopic evaluation of swallowing is performed given the concern for oropharyngeal dysphagia. This demonstrates normal tongue movement and mastication but mild weakness of the oropharyngeal phase of swallow. A barium swallow is performed, which displays a medium-sized pharyngeal pouch, and Susan is referred for ENT assessment.
Given her age and significant comorbidities, there is concern regarding any surgical management of her condition. She decides to opt for conservative management after an extensive discussion regarding the potential risks of surgical techniques, including endoscopic or open diverticulectomy.
She is counselled and also assessed by a dietitian, with recommendations to modify her diet to make it easier to chew and swallow, eating slowly and taking smaller mouthfuls, drinking small sips of liquids during the meal. Her symptoms remain tolerable, and she is able to regain weight.
CONCLUSION
DYSPHAGIA can be a troubling symptom and may lead to significant morbidity in the form of weight loss, malnutrition and social isolation. It is one of the more common conditions encountered by GPs given the high prevalence in the community.
The evaluation of dysphagia always starts with a detailed and thorough history, particularly to delineate between oropharyngeal and oesophageal causes. This will assist in determining the appropriate pathway for investigation and specialist referral.
Most patients will require an endoscopy— primarily to rule out mechanical obstruction. However, investigations, such as a barium swallow or manometry, can be crucial in reaching a diagnosis.
The management of dysphagia depends on the underlying aetiology, as well as patient factors, and may include conservative approaches, such as dietary modification, medical management, endoscopic treatment or surgery.
RESOURCES
• UpToDate patient information: Dysphagia( the basics)— subscription required bit. ly / 4isiyET
• Aust Fam Physician 2015; Oct. bit. ly / 3XrmyNL
• Ann Rehabil Med 2023; 30 Jul. bit. ly / 3F7i74r
• Am J Gastroenterol 2023; Dec. bit. ly / 3F6OobJ
• Gastroenterol Clin North Am 2020; 14 Jun. bit. ly / 3XvNRX5
• Am J Gastroenterol 1998; Mar. bit. ly / 4bopEId
References Available on request from howtotreat @ adg. com. au