Published online Feb 14, 2017. doi: 10.3748/wjg.v23.i6.1038
Peer-review started: October 12, 2016
First decision: November 21, 2016
Revised: January 4, 2017
Accepted: January 18, 2017
Article in press: January 18, 2017
Published online: February 14, 2017
To determine if patients can localise dysphagia level determined endoscopically or radiologically and association of gender, age, level and pathology.
Retrospective review of consecutive patients presenting to dysphagia hotline between March 2004 and March 2015 was carried out. Demographics, clinical history and investigation findings were recorded including patient perception of obstruction level (pharyngeal, mid sternal or low sternal) was documented and the actual level of obstruction found on endoscopic or radiological examination (if any) was noted. All patients with evidence of obstruction including oesophageal carcinoma, peptic stricture, Schatzki ring, oesophageal pouch and cricopharyngeal hypertrophy were included in the study who had given a perceived level of dysphagia. The upper GI endoscopy reports (barium study where upper GI endoscopy was not performed) were reviewed to confirm the distance of obstructing lesion from central incisors. A previously described anatomical classification of oesophagus was used to define the level of obstruction to be upper, middle or lower oesophagus and this was compared with patient perceived level.
Three thousand six hundred and sixty-eight patients were included, 42.0% of who were female, mean age 70.7 ± 12.8 years old. Of those with obstructing lesions, 726 gave a perceived level of dysphagia: 37.2% had oesophageal cancer, 36.0% peptic stricture, 13.1% pharyngeal pouches, 10.3% Schatzki rings and 3.3% achalasia. Twenty-seven point five percent of patients reported pharyngeal level (upper) dysphagia, 36.9% mid sternal dysphagia and 25.9% lower sternal dysphagia (9.5% reported multiple levels). The level of obstructing lesion seen on diagnostic testing was upper (17.2%), mid (19.4%) or lower (62.9%) or combined (0.3%). When patients localised their level of dysphagia to a single level, the kappa statistic was 0.245 (P < 0.001), indicating fair agreement. 48% of patients reporting a single level of dysphagia were accurate in localising the obstructing pathology. With respect to pathology, patients with pharyngeal pouches were most accurate localising their level of dysphagia (P < 0.001). With respect to level of dysphagia, those with pharyngeal level lesions were best able to identify the level of dysphagia accurately (P < 0.001). No association (P > 0.05) was found between gender, patient age or clinical symptoms with their ability to detect the level of dysphagia.
Patient perceived level of dysphagia is unreliable in determining actual level of obstructing pathology and should not be used to tailor investigations.
Core tip: Patient perception of the level of their dysphagia is only accurate in 48% of patients. It is most accurate for those with pharyngeal pouches and for those with pharyngeal or upper oesophageal pathology which might help guide initial investigations, e.g., to barium swallow. No other patient features or history helps determine patient accuracy. Endoscopists and radiologists should be aware of the importance of carefully examining the whole oesophagus to avoid missing pathology irrespective of a patient’s perceived level of dysphagia.