Dysphagia should prompt urgent gastroenterological referral
Dear Sir
We read with interest the recent Clinical Review of the
“Investigation and management of chronic dysphagia” by Leslie et al (1).
Whilst the article gave an excellent summary of dysphagia from an ENT
standpoint, we feel that an article directed at your general readership
should have placed more emphasis on gastroenterological causes.
From a gastro-intestinal perspective, dysphagia is an alarm symptom,
which should prompt urgent referral to exclude cancer. Indeed government
directives have led to the “two week wait” scheme. The quoted Department
of Health figures record 23000 diagnoses of dysphagia. To put this into
perspective, for oesophageal cancer, where the primary symptom is
dysphagia, there are approximately 7000 new cases each year(2),(3).
Leslie et al imply that patients referred with high dysphagia may be
safely assessed by ENT surgeons alone. However, it is important to note,
that whilst patients with “low” dysphagia will not have a pharyngeal
problem, patients with “high” dysphagia may have an oesophageal problem.
If ENT examination is unrevealing, then oesophageal examination should
certainly be carried out(4). Whilst barium studies may highlight
pathology in the cervical oesophagus and provide information regarding
motility, careful flexible endoscopy would be our preferred choice since
it permits both biopsy and therapeutic intervention.
Finally, we must take issue with the assertion that the rate of
oesophageal perforation following flexible endoscopy is 2.6%. We feel the
authors have misrepresented the article by Quine et al, which in fact
quotes an overall perforation rate of 0.05%. The much higher figure of
2.6% relates to therapeutic procedures such as dilatation(5). DOH figures
record 495,990 gastroscopies in the year 2001-2. They record 253
oesophageal perforations (all causes)(6). This suggests a maximum rate due
to endoscopy, of 0.05%. This makes flexible endoscopy an extremely safe
procedure and an appropriate first choice for the initial investigation of
dysphagia.
Yours faithfully,
Hal Spencer, Medical Registrar, Northern General Hospital, Sheffield,
S5 7AU
Stuart Riley, Consultant Gastroenterologist, Northern General Hospital,
Sheffield, S5 7AU
(1)BMJ 2003;326:433-6
(2) Cancer Research Campaign. Factsheet 1.1 Incidence-U.K.,1998.
Rapid Response:
Dysphagia should prompt urgent gastroenterological referral
Dear Sir
We read with interest the recent Clinical Review of the
“Investigation and management of chronic dysphagia” by Leslie et al (1).
Whilst the article gave an excellent summary of dysphagia from an ENT
standpoint, we feel that an article directed at your general readership
should have placed more emphasis on gastroenterological causes.
From a gastro-intestinal perspective, dysphagia is an alarm symptom,
which should prompt urgent referral to exclude cancer. Indeed government
directives have led to the “two week wait” scheme. The quoted Department
of Health figures record 23000 diagnoses of dysphagia. To put this into
perspective, for oesophageal cancer, where the primary symptom is
dysphagia, there are approximately 7000 new cases each year(2),(3).
Leslie et al imply that patients referred with high dysphagia may be
safely assessed by ENT surgeons alone. However, it is important to note,
that whilst patients with “low” dysphagia will not have a pharyngeal
problem, patients with “high” dysphagia may have an oesophageal problem.
If ENT examination is unrevealing, then oesophageal examination should
certainly be carried out(4). Whilst barium studies may highlight
pathology in the cervical oesophagus and provide information regarding
motility, careful flexible endoscopy would be our preferred choice since
it permits both biopsy and therapeutic intervention.
Finally, we must take issue with the assertion that the rate of
oesophageal perforation following flexible endoscopy is 2.6%. We feel the
authors have misrepresented the article by Quine et al, which in fact
quotes an overall perforation rate of 0.05%. The much higher figure of
2.6% relates to therapeutic procedures such as dilatation(5). DOH figures
record 495,990 gastroscopies in the year 2001-2. They record 253
oesophageal perforations (all causes)(6). This suggests a maximum rate due
to endoscopy, of 0.05%. This makes flexible endoscopy an extremely safe
procedure and an appropriate first choice for the initial investigation of
dysphagia.
Yours faithfully,
Hal Spencer, Medical Registrar, Northern General Hospital, Sheffield,
S5 7AU
Stuart Riley, Consultant Gastroenterologist, Northern General Hospital,
Sheffield, S5 7AU
(1)BMJ 2003;326:433-6
(2) Cancer Research Campaign. Factsheet 1.1 Incidence-U.K.,1998.
(3)Aliment Pharmacol Ther. 2003 Mar;17(5):655-64
(4)J Laryngol Otol 1993 Jun;107(6):535-7
(5)Br J Surg 1995 Apr;82(4):530-3
(6) Department of Health. Hospital in patient data. www.doh.gov.uk/hes
Competing interests:
None declared
Competing interests: No competing interests