Wednesday, August 12, 2015

Dysphagia

Today's highlighted some of the areas of medicine less commonly featured in morning report.

The case involved a 38-year-old woman with a history of GERD and a motor vehicle collision several years prior to her admission. She presented with a 5-month history of progressive dysphagia, first to solids then to liquids with globus sensation.  She had lost a significant amount of weight.  There were no systemic features to suggest a connective tissue disorder such as systemic sclerosis.  There were also no bulbar or cranial nerve features to suggest a central nervous system cause.  Finally, she had no fatigability suggestive of a myasthenic cause.  As the case progressed, an extensive number of ‘outside’ investigations was revealed including an esophagogastroduodenoscopy, motility study, and barium swallow which effectively ruled out an intraluminal cause of dysphagia.  It was then revealed that there were substantial psychosocial stressors and, when the psychiatry consult-liason team was involved, her presentation was consistent with a somatoform disorder.



Important learning points from today:

-Dysphagia is a common symptom with a wide differential diagnosis

-It is helpful to divide dysphagia into obstructive (extrinsic/intrinsic mass, peptic strictures) and propulsive (achalasia, neuromuscular disorders, central nervous system/coordination) causes

-We discussed salient historic features that can help differentiate them – these include a progressive dysphagia from solids to liquids (more consistent with an obstructive cause) compared to dysphagia which begins with solids and liquids (consistent with a neuromuscular cause)

-We briefly discussed the infections in an immunocompromised host that would lead to esophageal dysphagia including opportunistic infections with Herpes group viruses, or esophageal candidiasis

-We discussed features of brainstem and bulbar disease and the importance about acquiring those symptoms when taking a dysphagia history (dysphonia, dysarthria, nasal vocal changes, hoarseness, etc.)

-Importantly, we discussed the concept of psychiatric or somatoform disease as a diagnosis of exclusion and that it can be challenging to deem someone having been ‘investigated enough’ for ‘organic’ causes of symptoms

Further Reading:

Mathog, R. H., & Fleming, S. M. (1992). A clinical approach to dysphagia. American journal of otolaryngology13(3), 133-138.






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