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Try this quiz on causes of dysphagia! 

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Approach to the patient with dysphagia

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Question 1

Stem 1, question 1 of 5

Hyacinth, a 66 year old female, presents to her GP with 4 month history of difficulty swallowing.
Which of the following is NOT a risk factor for gastro-oesophageal reflux disease (GORD)?
A
Family history
B
Inguinal hernia
C
Obesity
D
Older age
E
Hiatus hernia
Question 1 Explanation: 
GORD is just the gift that keeps on giving! There a number of risk factors for GORD which are important to know, here are a select few. An inguinal hernia is not a risk factor for GORD but for incarceration of bowel if it becomes strangulated in the inguinal ring.
Question 2

Stem 1, question 2 of 5

The GP performs some blood tests with the following report: Iron deficiency anaemia. No other abnormalities detected
What is the most likely cause of Hyacinth's dysphagia?
A
Gastro-oesophageal reflux disease
B
Oesophageal web
C
Malignant stricture
D
Heart failure
E
Scleroderma
Question 2 Explanation: 
An oesophageal web is a thin mucosal membrane that grows across the lumen of the oesophagus leading to dysphagia and is linked to iron deficiency anaemia. You would be correct in suspecting malignancy given her age and iron deficiency anaemia but that is more likely to a colon cancer rather than upper GI. The other three answers do not have the same association with iron deficiency anaemia.
Question 3

Stem 1, question 3 of 5

5 years later Hyacinth returns with dysphagia. Her PMH includes an MI 3 years ago and she takes aspirin, atorvastatin, furosemide and amlodipine. Examination reveals displaced apex beat and pitting oedema to mid calf.
What anatomical relation of the oesophagus is the cause of Hyacinth's dysphagia?
A
Lungs
B
Thymus
C
Thyroid
D
Heart
E
Stomach
Question 3 Explanation: 
There are a number of pointers towards cardiac causes in the stem, such as the PMH, medications and examination findings, all building up a picture of heart failure. Hypertrophy of the myocardium, especially the atria, can result in extrinsic compression of the oesophagus and thus dysphagia. Enlargement and dysfunction of all the other organs listed can cause dysphagia but do not fit the clinical picture.
Question 4

Stem 1, question 4 of 5

GORD can be treated with a proton pump inhibitor. Which of the following is a proton pump inhibitor (PPI)?
A
Cimetidine
B
Ranitidine
C
Calcium carbonate
D
Magnesium hydroxide
E
Omeprazole
Question 4 Explanation: 
PPIs are very commonly prescribed and so they are a key drug to remember! Omeprazole is a common example of a PPI. Cimetidine and ranitidine are H2 antagonists which can also be used for dyspepsia. Calcium carbonate and magnesium hydroxide are gastric acid neutralisers.
Question 5

Stem 1, question 5 of 5

What is a complication of Gastro-oesophageal reflux?
A
Malignant strictures
B
Achalasia
C
Scleroderma
D
Barrett's oesophagus
E
Myasthenia gravis
Question 5 Explanation: 
Hopefully this was a nice reassuring and easier question for you. Barrett's oesophagus is a complication of GORD and does predispose an individual to oesophageal cancer. The other options are not complications of oesophageal cancer but other causes of dysphagia
Question 6

Stem 2, question 1 of 3

Benedict, a 54 year old male, presents with a 6 month history of heartburn, regurgitation and dysphagia unrelated to food. He has intermittent dysphagia to both solids and liquids. He describes a "gurgling" sound in his chest
What is the most likely diagnosis?
A
Scleroderma
B
Achalasia
C
Extrinsic compression
D
Bulbar palsy
E
Myasthenia gravis
Question 6 Explanation: 
Achalasia is a type of motility disorder affecting peristalsis that presents with dysphagia, retrosternal pain, regurgitation and gradual weight loss. Scleroderma is a multi system autoimmune disease, extrinsic compression refers to the squashing of the oeseophagus by another structure. Bulbar palsy is a lower motor neuron lesion and myasthenia gravis is an autoimmune disease.
Question 7

Stem 2, question 2 of 3

Benedict is referred for further investigations
What is the most likely investigation result for Benedict?
A
Positive Acetylcholine receptor antibody assay
B
Upper GI endoscopy with mucosa obscured by retained salvia with frothy appearance
C
Thin protections off anterior surface of post cricoid oesophagus seen on endoscopy
D
Low lower oesophageal sphincter pressure on manometry
E
Mediastinal mass seen on CT chest
Question 7 Explanation: 
There are a number of investigations for achalasia: Upper GI endoscopy, Barium swallow tests, oesophageal manometry. Let's break down the answer options: A positive acetylcholine receptor antibody assay is seen in Myasthenia Gravis. Thin projections off anterior surface of post cricoid oesophagus will be seen in oesophageal webs. Low lower oesophageal sphincter pressure on manometry is seen in scleroderma. Mediastinal masses can be seen in a number of conditions such as metastatic cancers.
Question 8

Stem 2, question 3 of 3

What causes achalasia?
A
Functional and structural abnormalities of small blood vessels, fibrosis of skin and internal organs and production of auto-antibodies
B
Symptoms or complications resulting from the reflux of gastric contents into the oesophagus or beyond into the oral cavity or lung
C
An abnormal narrowing of the oesophageal lumen
D
A chronic autoimmune disorder of the post synaptic membrane at the neuromuscular junction in skeletal muscle
E
Loss of oesophageal peristalsis and failure of the lower oesophageal sphincter to relax in response to swallowing
Question 8 Explanation: 
Achalasia is a motility disorder with the loss of peristalsis in the oesophagus. The other answer options refer to the following conditions respectively: Scleroderma, GORD, stricture, myasthenia gravis
Question 9
Daphne presents to her GP with dysphagia, muscle weakness and ptosis. She reports the symptoms worsen throughout the day
Which of the following drugs will treat her condition?
A
Neostigmine
B
Tetrabenazine
C
Rasagaline
D
Pramipexole
E
Suxamethonium
Question 9 Explanation: 
A harder question again so relish the challenge! The stem is describing myasthenia gravis which is characterised by increasing fatigue with muscle use, thus symptoms worsen throughout the day. Myasthenia Gravis is treated with peripheral acetylcholinesterase inhibitors, of which neostigmine is an example of, to increase the amount of Acetylcholine available in the neuromuscular junction. The other drugs are used for the following respectively: Huntington's disease, Parkinson's disease, Parkinson's disease and depolarising neuromuscular blocker.
Question 10
Eloise is diagnosed with scleroderma following episodes of dysphagia
Which of the following is NOT a treatment option for scleroderma related dysphagia?
A
Omeprazole
B
Domperidone
C
Corticosteroids
D
Lifestyle changes
E
Erthromycin
Question 10 Explanation: 
According to BMJ Best Practice (Feb 2021) corticosteroids are not used to treat scleroderma-related dysphagia (but it is used to manage other features of scleroderma). Erythromycin and domperidone are used as pro-kinetic agents and omeprazole and lifestyle changes address GORD. Note that domperidone has a small risk of life-threatening cardiac events and therefore care should be given when prescribing it; it should only be used to treat the nausea and vomiting.
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