Dysphagia

Who to refer:

• All patients with oesophageal dysphagia should be urgently referred for upper GI endoscopy.
• 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 – Please refer to the ENT page but  if there is any doubt about the nature of dysphagia, especially in older patients, then refer to GI for full upper endoscopy as the site where patients localise food sticking often correlates poorly with the actual site of any lesion.
• 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).

Who not to refer:

• A “feeling of something in the throat” is very rarely cancer.  Particularly in young non-smokers, the chance of a malignant diagnosis is low and such patients should not be referred on the cancer pathway if at all possible. See ENT page for advice.

How to refer: 

Referral is via SGI Gateway to endoscopy. Once the referral is received, Endoscopy will triage the referral

Borders General Hospital -> Endoscopy -> B Endoscopy     

What Information should be included in referral under Referral Text Tab:

There are seven factors specifically associated with increased cancer risk in dysphagia. Age and sex are automatically detailed under the Patient Demographics tab, information on the other five factors should be included in the referral.

• Short duration of symptoms (<6 months)
• Absence of acid reflux when presenting with dysphagia
• Food sticking in the chest rather than neck
• Recent non-intentional weight loss over 3kg.
• Progressive nature of dysphagia  

It is particularly important to provide accurate information on these 7 factors specifically associated with a significantly high risk of cancer as these factors can identify a sub-group of patients with up to a 10% risk of cancer. Please include details of each in the 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.

Specific points to be asked when taking the history from a patient:

• History of smoking and alcohol intake.
• History of neurological disease or CVA.
• Drugs History (e.g. bisphosphonates, NSAIDs, aspirin, nitrates, calcium antagonists). Not all information on medications provided may be included under the Medication Tab so please include details of any relevant previous medications.
• 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.

bor.gastroenterology@borders.scot.nhs.uk