Services
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Gastrointestinal medical OPD clinics take place at:
- Leith CTC
- RIE
- St John’s Hospital
- WGH
Who to refer:
Dysphagia is an alarm symptom requiring urgent investigation & referral.
- All patients with oesophageal dysphagia should be urgently referred to upper GI for urgent endoscopy.
- If dysphagia persists despite a normal endoscopy, these patients merit further investigations and referral to an upper GI specialist to exclude dysmotility such as achalasia.
- Difficulty to initiate swallow may indicate the presence of neurological disease or an ENT cause (e.g. CVA) – consider ENT/SLT referral for assessment of swallowing mechanism.
- Feeling of food sticking high in the neck or back of the throat – consider ENT referral.
- High (neck) dysphagia with hoarse voice – consider ENT referral.
- Patients with dysphagia should NOT be referred for barium swallow from primary care without prior consultation with the appropriate specialist (GI or ENT).
Who not to refer:
Any patient with dysphagia requires urgent referral.
How to refer:
Via SCI Gateway
Information to include in referral:
Detailed clinical history to characterise dysphagia is important.
- Difficulty to initiate swallow may indicate the presence of neurological disease (e.g. CVA)
- For any patient >50 years presenting with a clear description of food sticking following initiation of swallow (oesophageal dysphagia), the concern is that this alarm symptom may herald the presence of oesophageal cancer.
- Intermittent swallowing difficulty for both liquids and solids following initiation of swallow, particularly in the young patient, may indicate the presence of oesophageal dysmotility such as achalasia.
Approximately 10% of patients presenting with dysphagia will be diagnosed with oesophageal cancer.
Another 15-20% will have significant non-cancer pathology requiring treatment such as complicated GORD (oesophagitis, benign strictures, Barrett’s) or a dysmotility syndrome such as achalasia.
Specific points to be asked when taking a history of a patient with dysphagia (Dictation Checklist):
- History of smoking and alcohol.
- History of neurological disease or CVA.
- Drugs History (e.g. biphosphonates, NSAIDs, aspirin).
- History of GORD.
- History of previous investigations for dysphagia.
Factors suggestive of sinister cause for dysphagia (both cancer or non-cancer related):
- Odynophagia.
- Hoarse voice (consider ENT referral).
- Coexisting iron deficiency anaemia.
- Coughing / choking during or after drinking.
- Progressive dysphagia particularly for solids.
- Regurgitation.
Six factors specifically associated with increased cancer risk in dysphagia:
- Recent non-intentional weight loss over 3kg.
- Male gender.
- Absence of acid reflux when presenting with dysphagia.
- Food sticking in the chest rather than neck.
- Older patient (risk increases significantly with age).
- Short duration of symptoms (<6 months).
It is particularly important to provide accurate information on the 6 factors specifically associated with significantly high risk of cancer as these factors can identify a sub-group of patients with up to 20% risk of cancer.