How can I differentiate between benign and malignant causes of dysphagia in my patients?

To differentiate between benign and malignant causes of dysphagia in patients, a detailed clinical assessment focusing on symptom characteristics and risk factors is essential. Malignant dysphagia often presents with progressive, painless difficulty swallowing solids initially, which may later include liquids, accompanied by weight loss, anorexia, and possibly odynophagia or haematemesis NICE NG12. In contrast, benign causes typically cause intermittent or non-progressive dysphagia, often associated with pain or discomfort and may be linked to a history of gastroesophageal reflux or eosinophilic esophagitis Kruger 2014.

Red flag features suggesting malignancy include: age over 55, unintentional weight loss, persistent vomiting, evidence of upper gastrointestinal bleeding, and a history of smoking or alcohol excess NICE NG12. Benign dysphagia is more likely in younger patients without systemic symptoms and with a history of benign conditions such as strictures, webs, or motility disorders Kruger 2014.

Physical examination and initial investigations such as upper GI endoscopy are crucial; malignancy often shows obstructive lesions or masses, whereas benign causes may reveal strictures, rings, or inflammation NICE NG12. Imaging and biopsy confirm diagnosis. Manometry may help differentiate motility disorders from structural causes Kruger 2014.

In summary, the differentiation relies on clinical features, risk stratification, and targeted investigations: progressive, painless dysphagia with systemic symptoms and risk factors points to malignancy, while intermittent, painful dysphagia without systemic signs suggests benign causes NICE NG12 Kruger 2014.