Dysphagia
Dysphagia is difficulty in swallowing solids, liquids, or both, resulting from functional or structural impairment of the oral, pharyngeal, or esophageal phases of deglutition.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | GORD / peptic stricture [3] | Long Hx of heartburn → progressive solid-food dysphagia | 「你之前有冇長期胃酸倒流？」(Long-standing reflux?) |
| Oesophageal candidiasis | Immunocompromised + odynophagia + white plaques | 「你有冇食緊類固醇或者免疫力差嘅病？」 | |
| Serious Not To Miss | Oesophageal carcinoma (SCC or adenoCA) [1] | Progressive dysphagia solids → liquids + weight loss + smoking/alcohol | 「吞嘢困難有冇由固體變到連水都難？體重輕咗幾多？」 |
| Gastric cardia / GOJ cancer [7] | Dysphagia + early satiety + weight loss | 「食少少就覺得飽？」(Early satiety?) | |
| Stroke / neurological cause | Acute onset, hemiplegia, dysarthria, nasal regurgitation [5] | 「吞嘢困難係唔係突然嚟嘅？有冇手腳冇力？」 | |
| Pitfalls | Achalasia | Solids + liquids from onset, regurgitation, relieved by repeated swallows | 「係唔係一開始就固體同水都難吞？吞多幾次會唔會好啲？」 |
| Eosinophilic oesophagitis | Young, atopic, intermittent food impaction | 「你有冇濕疹、哮喘？有冇試過食嘢突然卡住？」 | |
| Pharyngeal pouch (Zenker's) | Elderly, halitosis, regurgitation of undigested food without acid taste [4] | 「嘔返出嚟嘅嘢有冇酸味？有冇口臭？」 | |
| Masquerades | Iron deficiency anaemia (Plummer-Vinson) [8] | Webs + IDA + glossitis + angular cheilitis | 「你有冇覺得好攰？指甲有冇變形？」 |
| Scleroderma oesophagus | Raynaud's, skin tightening, heartburn + dysphagia | 「你隻手指凍嗰陣有冇變白或者變藍？」 | |
| Depression / anxiety (globus sensation) | Sensation of lump in throat, no true dysphagia to solids/liquids, worse with stress | 「你係覺得喉嚨有嘢頂住，定係真係吞唔落？」 | |
| Trying to Tell Me Something? | Cancer anxiety / globus from stress | Worried after someone close diagnosed with CA; no red flags | 「有冇咩嘢令你特別擔心呢？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, set agenda | 「你好呀，我係X醫生，今日想同你傾下你嘅情況，大約傾六分鐘，中間有咩想補充隨時講。」 | Friendly opening, signposting → interpersonal marks |
| 0:30–1:30 | Chief complaint + HPI: symptom analysis | 「你覺得吞嘢有咩困難呀？幾時開始㗎？」「係固體嘢卡住定係連水都吞唔到？」「有冇越嚟越差？」 | Establishes oropharyngeal vs oesophageal, progressive vs intermittent → key discriminator |
| 1:30–3:00 | Red flags, associated Sx, systems review | 「有冇痛？有冇嘔血或者痾黑屎？體重有冇輕咗？」「有冇俾嘢卡住胸口嘅感覺？」 | Screens for malignancy, stricture, bleeding. Red flags = must-ask |
| 3:00–4:00 | PMH, drugs, FHx, social Hx (smoking, alcohol, diet) | 「以前有冇乜嘢病？食緊咩藥？有冇食NSAID或者薄血丸？屋企人有冇試過生癌？你有冇飲酒、食煙？」 | Drug-induced oesophagitis; risk factors for oesophageal CA (smoking + alcohol = SCC; obesity + GORD = adenoCA) |
| 4:00–5:00 | ICE + hidden agenda | 「你自己覺得係咩事呢？」(Idea)「你最擔心啲咩？」(Concern)「你嚟睇醫生最希望我幫到你啲咩？」(Expectation) | ICE is separately marked. Hidden agenda often = cancer fear after family/friend diagnosis |
| 5:00–5:30 | Summarise back, check understanding | 「等我總結一下，你話吞嘢越嚟越困難，由固體到而家連粥都難吞，仲輕咗十磅，係咪咁？」 | Shows active listening; lets patient correct |
| 5:30–6:00 | Empathy, plan, safety net, close | 「我明白你好擔心，我哋安排你照個胃鏡（OGD）睇清楚。如果中間吞嘢完全吞唔到或者嘔血，要即刻去急症室。」 | Empathy + clear plan + safety net = strong close |
Uncovering the hidden agenda: Ask 「點解今日嚟呀？」 or 「係咩令你決定嚟睇醫生？」— the patient may have been tolerating symptoms for weeks but came today because a relative was diagnosed with cancer, or because they choked badly.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & duration | When did the swallowing difficulty start? | 「幾時開始覺得吞嘢有困難？」 | Acute → foreign body/stroke; gradual → stricture/CA | Weeks–months progressive → malignancy |
| Solids vs liquids | Is it solids only, or liquids too? | 「係吞固體嘢難，定係連水都難吞？」 | Solids only → mechanical obstruction; solids + liquids from start → motility disorder [1] | Solids only → CA, stricture; both → achalasia, scleroderma |
| Level of obstruction | Where do you feel it sticks? | 「你覺得啲嘢卡喺邊度？喉嚨定胸口？」 | Throat → oropharyngeal; chest → oesophageal [1] | Throat + cough/nasal regurgitation → oropharyngeal dysphagia |
| Progression | Is it getting worse? | 「有冇越嚟越差？」 | Progressive → CA/stricture; intermittent → ring/spasm [1] | Rapidly progressive (weeks) = red flag for CA |
| Odynophagia | Is it painful to swallow? | 「吞嘢嗰陣痛唔痛？」 | Pain → oesophagitis, ulcer, infection | Immunocompromised + odynophagia → Candida/HSV/CMV oesophagitis |
| Weight loss | Have you lost weight? | 「最近體重有冇輕咗？輕咗幾多？」 | > 10% in 12 months is a red flag for malignancy [2] | Oesophageal/gastric CA |
| Heartburn / reflux | Any acid reflux or heartburn? | 「有冇胃酸倒流或者心口灼熱？」 | Chronic GORD → peptic stricture or Barrett's → adenoCA [3] | Peptic stricture, Barrett's oesophagus |
| Regurgitation | Do you bring up undigested food? | 「有冇嘔返啲未消化嘅嘢出嚟？」 | Regurgitation of old food → pharyngeal pouch / achalasia [4] | Zenker's diverticulum, achalasia |
| Choking / cough / nasal regurgitation | Do you choke or cough when eating? Food come out your nose? | 「食嘢有冇嗆到？有冇由鼻度出返嚟？」 | Oropharyngeal dysphagia; aspiration risk [5] | Stroke, MND, myasthenia gravis, bulbar palsy |
| Neurological Sx | Any weakness, speech problems, or vision changes? | 「手腳有冇冇力？講嘢有冇唔清楚？」 | Neurological cause of oropharyngeal dysphagia | CVA, MG, Parkinson's, motor neurone disease |
| Bleeding | Any vomiting blood or dark stool? | 「有冇嘔血或者痾黑屎？」 | Upper GI bleed from ulceration/tumour [2] | Oesophageal CA with ulceration |
| Drug Hx | What medications do you take? Any NSAIDs, bisphosphonates, doxycycline, KCl? | 「你食緊咩藥？有冇食止痛藥、骨質疏鬆藥？」 | Drug-induced oesophagitis/stricture [6] | Pill oesophagitis |
| Smoking & alcohol | Do you smoke or drink? | 「你有冇食煙飲酒？」 | Smoking + alcohol = major risk factors for oesophageal SCC [1] | Oesophageal SCC |
| PMH | Any history of GORD, Barrett's, scleroderma, stroke, head/neck cancer? | 「以前有冇胃酸倒流、硬皮症、中風、頭頸癌？」 | Identifies predisposing conditions | Peptic stricture, scleroderma oesophagus, post-stroke dysphagia |
| FHx | Any family history of GI cancer? | 「屋企人有冇試過生食道癌或者胃癌？」 | Family Hx of upper GI CA → higher risk [2] | Oesophageal / gastric malignancy |
| Functional impact | Can you still eat normal food? How does this affect your daily life? | 「你而家仲食唔食到正常嘢？對你日常生活有冇影響？」 | Assesses nutritional status and social impact | Malnutrition, social isolation |
| ICE | What do you think is causing this? What worries you most? What would you like me to do? | 「你自己覺得係咩原因？你最擔心啲咩？你最希望我點幫你？」 | Separately scored on CRF | Cancer fear is common hidden concern |
Case Report Form Answer Builder
Template: "Dysphagia for [duration]. Progressive difficulty swallowing [solids → solids + liquids / solids only]. Associated [weight loss of X kg / odynophagia / regurgitation / heartburn / nil]. [Red flags present/absent: weight loss, GI bleeding, anorexia]. Background of [smoking/alcohol/GORD/nil]. No neurological symptoms."
High-yield HPI points to capture:
- Duration and tempo (acute vs progressive)
- Solids vs liquids vs both
- Level (throat vs chest)
- Associated: weight loss, bleeding, odynophagia, heartburn, regurgitation, choking
- Risk factors: smoking, alcohol, GORD, medications
- Absence of neurological symptoms (if relevant)
| Likely RFC | How to Phrase |
|---|---|
| Worsening dysphagia affecting oral intake | "Progressive dysphagia causing inability to eat solid food and weight loss" |
| Concern about cancer | "Fear of oesophageal cancer after progressive dysphagia" |
| Episode of food impaction | "Acute food impaction prompting ED/GP visit" |
Pick the reason that explains why today — often it's a tipping-point event (can't eat rice, choked badly, relative diagnosed with cancer).
| Component | Likely Content | Example Wording for CRF |
|---|---|---|
| Idea | "I think something is blocking my food pipe" or "Maybe it's just getting older" | Patient thinks food is stuck due to a growth |
| Concern | "I'm worried it could be cancer" | Patient fears oesophageal cancer, especially with weight loss |
| Expectation | "I want a scope / I want to know what's wrong" | Patient expects referral for OGD and definitive diagnosis |
For a typical exam vignette (elderly male, smoker/drinker, progressive solid-food dysphagia + weight loss):
Oesophageal carcinoma [1]
Minimum supporting evidence: progressive dysphagia from solids to liquids, significant weight loss, smoking/alcohol history, age > 50.
High Yield from GC Lecture
GC 189 emphasises: approach dysphagia by first classifying oropharyngeal vs oesophageal, then mechanical vs neuromuscular. Progressive solid-food dysphagia with weight loss in a smoker/drinker = oesophageal SCC until proven otherwise. [1]
If the vignette instead features a young patient with intermittent food impaction + atopy → eosinophilic oesophagitis. If long-standing heartburn + solid-food dysphagia → peptic stricture.
| DDx | Key Discriminator |
|---|---|
| Peptic stricture | Long history of GORD/heartburn, solid-food dysphagia, responds to PPI + dilatation [3] |
| Achalasia | Dysphagia to solids AND liquids from onset, regurgitation of undigested food, bird-beak on barium swallow [1] |
| Extrinsic compression (e.g. lung CA, mediastinal LN) | Concurrent respiratory symptoms, known malignancy, CXR abnormality [9] |
Alternative high-yield DDx depending on stem: stroke (acute + neuro signs), pharyngeal pouch (elderly, halitosis), eosinophilic oesophagitis (young, atopic).
| Domain | Problem |
|---|---|
| Biological | Progressive dysphagia causing malnutrition and weight loss; risk of aspiration pneumonia |
| Psychological | Anxiety and fear of cancer diagnosis; low mood from inability to eat normally |
| Social | Cannot participate in social meals (functional and social isolation); may need time off work for investigations; caregiver burden if dependent on modified diet |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports |
|---|---|---|---|
| Oesophageal carcinoma (most likely Dx) | Left supraclavicular lymphadenopathy (Virchow's node / Troisier's sign) | Palpate left supraclavicular fossa with patient sitting; ask patient to perform Valsalva to make node more prominent | Metastatic spread from intra-abdominal / lower oesophageal malignancy via thoracic duct [1] |
| Peptic stricture | No specific physical sign in brief FM station | Check for signs of chronic GORD (dental erosion) or anaemia (pallor, koilonychia) | Pallor suggests chronic blood loss from oesophagitis/ulcer |
| Achalasia | No reliable bedside sign | Best clue: barium swallow showing bird-beak narrowing; manometry is gold standard | Physical exam typically normal |
| Stroke (oropharyngeal dysphagia) | Asymmetric palatal movement / absent gag reflex / uvula deviation [5] | Ask patient to say "Ah" — observe palatal rise; test gag reflex bilaterally | CN IX/X palsy → oropharyngeal dysphagia with nasal regurgitation |
| Pharyngeal pouch | Neck swelling (left side, below SCM) that gurgles on palpation [4] | Palpate left side of neck; press gently — may produce gurgling or cause regurgitation | Pouch contains retained food; compresses oesophagus |
| Plummer-Vinson (IDA + webs) | Angular cheilitis, glossitis, koilonychia [8] | Inspect nails for spooning; inspect tongue for smooth/atrophic surface; inspect mouth corners | Signs of severe iron deficiency |
| Scleroderma | Skin thickening (sclerodactyly), Raynaud's, telangiectasia, microstomia | Inspect hands for tight shiny skin; ask about cold-induced colour changes | Systemic sclerosis causes oesophageal dysmotility |
Top Traps That Lose Marks
- Failing to distinguish oropharyngeal from oesophageal dysphagia — this is the first branch-point; the entire DDx hinges on it. Ask: "Where does it stick?" and "Do you choke/cough at the START of swallowing?"
- Missing weight loss — must quantify; > 10% in 12 months is a red flag [2].
- Not asking about solids vs liquids — mechanical obstruction = solids first then liquids; motility = both from the start [1].
- Confusing globus with true dysphagia — globus = constant lump-in-throat sensation, NO difficulty with actual swallowing of food. If the patient can eat and drink normally, it's not dysphagia.
- Forgetting drug history — pill oesophagitis (bisphosphonates, doxycycline, KCl, NSAIDs) is a common pitfall [6].
- Not eliciting ICE — this is separately scored. Cancer anxiety is extremely common.
Must-Not-Miss Red Flags → Urgent Referral:
- Progressive dysphagia + weight loss → 2-week-wait upper GI referral
- Complete dysphagia (can't swallow saliva) → emergency admission
- Haematemesis / melaena with dysphagia → emergency OGD
- New neurological signs + acute dysphagia → stroke pathway
Safety-Net Line (for closing):
「如果你完全吞唔到嘢、嘔血、或者痾黑屎，要即刻去急症室。」 ("If you cannot swallow at all, vomit blood, or pass black stool, go to A&E immediately.")
High Yield Summary
What to ASK: Oropharyngeal vs oesophageal? Solids vs liquids vs both? Progressive or intermittent? Weight loss? Bleeding? Smoking/alcohol? GORD history? Drug history? Neurological symptoms? ICE.
What to WRITE: Progressive solid-food dysphagia + weight loss + risk factors = oesophageal carcinoma until proven otherwise. Key DDx: peptic stricture (GORD hx), achalasia (solids + liquids from start), extrinsic compression. Biopsychosocial: malnutrition / cancer anxiety / social eating impairment.
What NOT to MISS: Weight loss quantification, Virchow's node on exam, drug-induced oesophagitis, and the patient's hidden cancer fear. Always classify oropharyngeal vs oesophageal first.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 189. I can't swallow oesophageal cancer.pdf (Definition, classification, approach to dysphagia, differential diagnosis) [2] Senior notes: Block A - Upper abdominal pain_ peptic ulcer; pancreatitis and gallstone.pdf (Red flag / alarming features including weight loss, dysphagia) [3] Lecture slides: Gastroenterology - Two cases of dyspepsia.pdf (Indications for endoscopy including dysphagia with alarming symptoms) [4] Senior notes: Ryan Ho GI.pdf p.68 (Pharyngeal pouch / Zenker's diverticulum; diffuse oesophageal spasm) [5] Senior notes: Ryan Ho Neurology.pdf p.22 (CN IX, X examination; oropharyngeal dysphagia assessment) [6] Taylor's Differential Diagnosis Manual 3ed.pdf p.214-216 (Medications causing oesophageal injury; approach to dysphagia) [7] Lecture slides: GC 212. Weight loss and vomiting gastric cancer; abdominal imaging.pdf [8] Senior notes: Ryan Ho Haemtology.pdf p.18 (Plummer-Vinson syndrome; IDA clinical features) [9] Senior notes: Ryan Ho Respiratory.pdf p.141-142 (Lung cancer causing oesophageal compression; intrathoracic spread)
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