Retrospective Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 14, 2017; 23(6): 1038-1043
Published online Feb 14, 2017. doi: 10.3748/wjg.v23.i6.1038
Can patients determine the level of their dysphagia?
Hafiz Hamad Ashraf, Joanne Palmer, Harry Richard Dalton, Carolyn Waters, Thomas Luff, Madeline Strugnell, Iain Alexander Murray
Hafiz Hamad Ashraf, Harry Richard Dalton, Carolyn Waters, Iain Alexander Murray, Departments of Gastroenterology, Royal Cornwall Hospital NHS Trust, Truro TR1 3LJ, United Kingdom
Joanne Palmer, Research and Development, Royal Cornwall Hospital NHS Trust, Truro TR1 3LJ, United Kingdom
Thomas Luff, Madeline Strugnell, Clinical Imaging, Royal Cornwall Hospital NHS Trust, Truro TR1 3LJ, United Kingdom
Author contributions: Murray IA conceived the idea; Ashraf HH and Murray IA designed the research; all authors were involved in data acquisition except Palmer J who analysed the data; Murray IA, Dalton HR and Ashraf HH wrote the paper and all authors have reviewed and contributed to the final version.
Institutional review board statement: The Research, Development and Innovation sponsorship team, Royal Cornwall Hospitals NHS Trust reviewed the study and decided that it did not require formal ethics approval as it was within the remit of audit.
Informed consent statement: The Research, Development and Innovation sponsorship team, Royal Cornwall Hospitals NHS Trust reviewed the study and decided that it did not require formal ethics approval as it was within the remit of audit and did not require formal patient consent as it involved a retrospective review of anonymised data.
Conflict-of-interest statement: Dalton HR has received travel and accommodation costs and consultancy fees from GlaxoSmithKline, Wantai and Roche, travel accommodation and lecture fees from Merck, Gilead and GFE Blut and travel and accommodation fees from the Falk and Gates Foundations. None of the other authors has any conflict of interest to disclose.
Data sharing statement: Statistical code and dataset available from the corresponding author at Consent was not obtained but the presented data are anonymised and risk of identification is low.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Iain Alexander Murray, BSc, MRCP, DM, Consultant Gastroenterologist, Departments of Gastroenterology, Royal Cornwall Hospital NHS Trust, 2 Penventinnie Ln, Treliske, Truro TR1 3LJ, United Kingdom.
Telephone: +44-1872-252717 Fax: +44-1872-252794
Received: October 11, 2016
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.

Keywords: Deglutition disorders, Oesophageal stenosis, Oesophageal neoplasm, Gastroscopy, Fluoroscopy, Patient perception, Pharyngeal pouch

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.