Investigating and managing chronic dysphagia

Editor—Leslie et al reviewed the investigation and management of chronic dysphagia well from an ear, nose, and throat stand-point,¹ but we think that an article directed at a general readership should have emphasised gastroenterological causes more.

From a gastrointestinal perspective, dysphagia is an alarm symptom that should prompt urgent referral to exclude cancer. Government directives have led to the two week wait scheme. The quoted Department of Health figures record 23 000 diagnoses of dysphagia. To put this into perspective, for oesophageal cancer, where the primary symptom is dysphagia, around 7000 new cases are diagnosed each year.²,³

Leslie et al imply that patients referred with high dysphagia may be safely assessed by ear, nose, and throat surgeons alone. However, although patients with “low” dysphagia will not have a pharyngeal problem, patients with “high” dysphagia may have an oesophageal problem. If ear, nose, and throat examination is unrevealing, then oesophageal examination should certainly be carried out.⁴ Although barium studies may highlight pathology in the cervical oesophagus and provide information on motility, careful flexible endoscopy would be our preferred choice since it permits both biopsy and therapeutic intervention.

We also disagree that the rate of oesophageal perforation after flexible endoscopy is 2.6%. We think that the authors have misrepresented the article by Quine et al, which quotes an overall perforation rate of 0.05%. The much higher figure of 2.6% relates to therapeutic procedures such as dilatation.⁵ Hospital episode statistics record 495 990 gastroscopies in the year 2001-2 and 253 oesophageal perforations (all causes). This implies a maximum rate due to endoscopy of 0.05%. This makes flexible endoscopy an extremely safe procedure and an appropriate first choice for the initial investigation of dysphagia.