Table 16

Investigation and management of low dyphagia

InvestigationsPotential resultsClinical management plan
Actions from history, medication and dietary assessment
History findingsDysphagia presentRefer for dietetic support.
Medication findings
  • Bisphosphonates


  • Potassium supplements

  • Tetracyclines

  • Theophyllines

Discuss possible alternative medications.
First line
If fistula unlikely OGD (no endoscopic intervention until discussed at the MDT)Stricture, if <6 months after upper GI surgeryOGD±dilatation (p. 25).
Consider treatment for acid/bile reflux (p. 25).
Stricture, if after radiotherapy or >6 months after upper GI surgeryOGD with careful biopsy and consider treatment for acid/bile reflux (p. 25).
CT±PET scan.
Then review in MDT before any further treatment/stent/dilatation (p. 25).
Inflammation (acid/bile)See management of acid or bile related inflammation (p. 25).
Local infection (viral/fungal)Treat infection appropriately.
Eosinophilic oesophagitisRefer to gastroenterology.
No obvious causeTake SI aspirate (p. 25) to exclude SIBO.
Arrange glucose hydrogen methane breath test.
Second line
Contrast swallow/CTFistula with aspirationThis is an emergency. Discuss with gastroenterology.
StrictureOGD with careful biopsy.
Refer to appropriate MDT requesting an appointment within 2 weeks to consider dilatation (p. 25)/stent insertion/other management.
Malignancy/tumour recurrenceRefer to appropriate MDT requesting an appointment within 2 weeks.
AchalasiaRefer to gastroenterology.
CT/MRI/PETMalignancy/tumour recurrence OtherRefer to appropriate MDT requesting an appointment within 2 weeks. Discussion supervising clinician within 24 weeks.
Third line
Oesophageal manometry/pH/impedance studiesAcid/bile refluxSee management of acidd/bile related inflammation (p.25).
Bile reflux
SpasmCalcium antagonist.
Low dose antidepressant, eg, citalopram.
Refer to gastroenterology.
SclerodermaStart PPI or H2 antagonist.
Refer to rheumatology.
Fourth line
If normal investigations/no response to interventionPsychological factorsRefer to psychology.
  • CT, computerised tomography; GI, gastrointestinal; H2, histamine receptor 2; MDT, multidisciplinary team; NSAID, non-steroidal anti-inflammatory drug; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); PET, positron emission tomography; PPI, proton pump inhibitor; SIBO, small intestinal bacterial overgrowth; SLT, speech and language therapy.