Clinical Review ABC of the upper gastrointestinal tract


BMJ 2001; 323 doi: (Published 13 October 2001) Cite this as: BMJ 2001;323:850
  1. William Owen

    Dysphagia is a distressing symptom and indicates a delay in the passage of solids or liquids from the mouth to the stomach. It is sometimes difficult to understand why patients may take so long to consult their doctor for advice, but whenever patients present a diagnosis should be urgently sought. Dysphagia should be distinguished from odynophagia, which is discomfort or pain on swallowing hot or cold liquids and, occasionally, alcohol.

    The use of bougies to remedy dysphagia caused by oesophageal stricture has been a standard treatment for centuries. (Reproduced from Robert Hooper's The Anatomist's Vade-Mecum 1805)

    In clinical practice it is useful to separate those causes that predominantly affect the pharynx and proximal oesophagus (high dysphagia) and those mostly affecting the oesophageal body and oesophagogastric junction (low dysphagia).

    Barium swallow showing cricopharyngeal spasm (arrow)

    Management of high dysphagia

    There may be pointers in a patient's history to a neuromuscular cause of high dysphagia such as neurological disease or a tendency for spillage into the trachea when the patient eats, producing coughing or choking. A patient may find it easier to swallow solids or semisolids rather than liquids and may also complain of nasal regurgitation of food. High dysphagia must be differentiated from globus hystericus (the feeling of having a lump in the throat without any true dysphagia). Globus is a common symptom, and when the patient is examined no abnormality is usually found. It is believed to be a functional disorder but is sometimes associated with gastro-oesophageal reflux.

    Generally, radiology is often more rewarding than endoscopy in clarifying the cause of high dysphagia. Cineradiography with liquid barium and bread soaked in barium may give valuable functional as well as anatomical information about the pharynx and cricopharyngeal segment. Most problems are related to failure of pharyngeal contraction or to cricopharyngeal relaxation, or a combination of …

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