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Clinical investigations from the RACP

Investigating patients with difficulty swallowing: the importance of a thorough history

Ian J Cook

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Abstract

A brief and logical history is the most useful diagnostic tool when investigating patients with dysphagia because it provides a reliable indication of the underlying pathology and dictates the subsequent investigative algorithm.

Key Points

  • A brief structured history is the single most important step in evaluating patients with dysphagia because it identifies the likely pathophysiological process in 85% of cases.
  • The history will generally reliably distinguish pharyngeal from oesophageal dysphagia and also a structural oesophageal disorder from dysmotility.
  • A common mistake is to confuse the common, purely sensory symptom of globus with dysphagia. The swallow is completely normal in patients with globus.
  • Endoscopy is almost invariably indicated in patients with dysphagia but, in some cases, a combination of endoscopy, radiography and oesophageal manometry is necessary to confirm a diagnosis.
  • The finding of a normal endoscopy and normal barium swallow does not adequately rule out a structural or mucosal oesophageal cause for dysphagia.

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