Dysphagia

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.

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