Investigation and management of low dyphagia
| Investigations | Potential results | Clinical management plan |
|---|---|---|
| Actions from history, medication and dietary assessment | ||
| History findings | Dysphagia present | Refer for dietetic support. |
| Medication findings |
| 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 surgery | OGD±dilatation (p. 25). Consider treatment for acid/bile reflux (p. 25). |
| Stricture, if after radiotherapy or >6 months after upper GI surgery | OGD 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 oesophagitis | Refer to gastroenterology. | |
| No obvious cause | Take SI aspirate (p. 25) to exclude SIBO. Arrange glucose hydrogen methane breath test. | |
| Second line | ||
| Contrast swallow/CT | Fistula with aspiration | This is an emergency. Discuss with gastroenterology. |
| Stricture | OGD with careful biopsy. Refer to appropriate MDT requesting an appointment within 2 weeks to consider dilatation (p. 25)/stent insertion/other management. | |
| Malignancy/tumour recurrence | Refer to appropriate MDT requesting an appointment within 2 weeks. | |
| Achalasia | Refer to gastroenterology. | |
| CT/MRI/PET | Malignancy/tumour recurrence Other | Refer to appropriate MDT requesting an appointment within 2 weeks. Discussion supervising clinician within 24 weeks. |
| Third line | ||
| Oesophageal manometry/pH/impedance studies | Acid/bile reflux | See management of acidd/bile related inflammation (p.25). |
| Bile reflux | ||
| Spasm | Calcium antagonist. Low dose antidepressant, eg, citalopram. Refer to gastroenterology. | |
| Scleroderma | Start PPI or H2 antagonist. Refer to rheumatology. | |
| Fourth line | ||
| If normal investigations/no response to intervention | Psychological factors | Refer 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.