On this page
Referral and warning signs
When to refer
Referral to specialist (Gastroenterology, ENT, Neurology, Speech Therapy) is usually required for diagnosis and management. Urgent referral if: Complete inability to swallow (food or saliva). Significant weight loss. Suspected malignancy. Signs of aspiration.
Red flags
- Complete obstruction (inability to swallow saliva)
- Significant unintentional weight loss
- Odynophagia (painful swallowing)
- Progressive symptoms
- Associated neurological symptoms (dysarthria, diplopia, weakness)
- Signs of aspiration (coughing with swallowing, recurrent pneumonia)
Signs and symptoms
- Oropharyngeal Dysphagia: Difficulty initiating swallow, coughing/choking during swallowing, nasal regurgitation, repetitive swallowing attempts, drooling, dysarthria (slurred speech), aspiration (may be silent).
- Oesophageal Dysphagia: Sensation of food sticking or lodging in the chest after swallowing, pain on swallowing (odynophagia), regurgitation of undigested food, heartburn.
- General: Weight loss, recurrent pneumonia (due to aspiration), halitosis (Zenker's, achalasia).
Risk factors
- Neurological conditions (Stroke, Parkinson's, Dementia, MS, Myasthenia Gravis, ALS)
- Muscular disorders (Polymyositis, Dermatomyositis)
- Structural abnormalities (Oropharyngeal/Oesophageal tumors, Zenker's diverticulum, webs/rings, strictures, extrinsic compression from nodes/tumours, osteophytes)
- Motility disorders (Achalasia, oesophageal spasm, scleroderma)
- Infections (Candida oesophagitis, HSV/CMV oesophagitis, Syphilis, Botulism, Rabies)
- Iatrogenic (Post-surgery, radiation therapy, chemotherapy, certain medications - e.g., neuroleptics, bisphosphonates causing pill oesophagitis)
- Metabolic (Cushing's, thyrotoxicosis, Wilson's)
- Gastroesophageal Reflux Disease (GERD) causing stricture/inflammation
Diagnosis
Clinical assessment
History is key: Differentiate oropharyngeal vs oesophageal. Difficulty with solids only (suggests mechanical obstruction) vs solids and liquids (suggests motility disorder or severe obstruction). Associated symptoms (pain, heartburn, weight loss, neurological deficits). Physical exam includes oral cavity, cranial nerves, neurological assessment, neck palpation.
Investigations
- Upper GI Endoscopy (OGD): Mandatory initial test for oesophageal dysphagia. Allows visualization, biopsy, dilation.
- Barium Swallow / Oesophagram: Useful for assessing motility disorders, strictures, rings, diverticula, extrinsic compression. Often complements endoscopy.
- Video Fluoroscopic Swallow Study (VFSS) / Modified Barium Swallow (MBS): Assesses oropharyngeal swallowing mechanics, useful for suspected aspiration.
- Oesophageal Manometry: Measures pressures and coordination of oesophageal muscle contractions. Gold standard for motility disorders (achalasia, spasm).
- Timed Water Swallow Test / Food Test (Clinical bedside tests).
- Blood tests: CBC, HIV serology, RBS, Electrolytes, Thyroid function tests (if relevant).
- CT/MRI scan: If extrinsic compression or neurological cause suspected.
Diagnostic criteria
Symptom of difficulty swallowing, with underlying cause identified through clinical assessment and investigations (esp. endoscopy, barium swallow, manometry).
Management
Non-pharmacological management
- Treat the Underlying Cause.
- Dietary Modification: Texture modification (soft, pureed foods), liquid consistency changes (thickened liquids) guided by swallow assessment, especially for oropharyngeal dysphagia.
- Swallowing Therapy / Compensatory Strategies: Taught by speech-language pathologist for oropharyngeal dysphagia (e.g., head positioning, specific maneuvers).
- Oesophageal Dilation: For benign strictures, rings, achalasia.
- Nutritional Support: Ensure adequate hydration and nutrition. May require supplemental feeding (NG tube, PEG tube) if oral intake unsafe or inadequate.
- Positioning during meals.
Pharmacological treatment
- Treat Underlying Cause:
- - GERD: PPIs (see GI011).
- - Infectious Oesophagitis: Antifungals (Fluconazole for Candida), Antivirals (Aciclovir for HSV).
- - Motility Disorders: Calcium channel blockers or nitrates may provide some relief in spasm. Botulinum toxin injection or specific medications for achalasia (specialist).
- - Neurological/Muscular Disorders: Treat underlying condition (e.g., Pyridostigmine for Myasthenia).
- Symptomatic relief medications have limited role for dysphagia itself.
Monitoring
- Monitor swallowing ability and safety.
- Monitor nutritional status and weight.
- Monitor for aspiration pneumonia.
- Monitor response to treatment of underlying cause.
Complications
- Aspiration pneumonia
- Malnutrition, dehydration, weight loss
- Choking
- Reduced quality of life
- Complications related to underlying disease (e.g., oesophageal perforation from dilation/tumour)
Prevention
- Manage conditions that cause dysphagia (stroke prevention, GERD control).
- Avoid medications known to cause pill oesophagitis without adequate water/upright posture.
- Head/neck cancer prevention (smoking/alcohol cessation).
Patient education
- Explain the nature of the swallowing difficulty and likely cause (if known).
- Dietary modifications and swallowing strategies.
- Importance of appropriate food/liquid consistency.
- Need for investigations (endoscopy etc.).
- Treatment plan for underlying cause.
- Signs of aspiration and when to seek help.
Uganda-specific notes
Oesophageal cancer and infectious oesophagitis (Candida in HIV) are important causes. Access to endoscopy, manometry, and specialist care is limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 6, Section 6.3.1