Department of Gastroenterology, Royal Cornwall Hospital, Truro, Cornwall TR1 3LJ, United Kingdom.
World J Gastroenterol. 2012 Aug 28;18(32):4357-62. doi: 10.3748/wjg.v18.i32.4357.
To determine which features of history and demographics predict a diagnosis of malignancy or peptic stricture in patients presenting with dysphagia.
A prospective case-control study of 2000 consecutive referrals (1031 female, age range: 17-103 years) to a rapid access service for dysphagia, based in a teaching hospital within the United Kingdom, over 7 years. The service consists of a nurse-led telephone triage followed by investigation (barium swallow or gastroscopy), if appropriate, within 2 wk. Logistic regression analysis of demographic and clinical variables was performed. This includes age, sex, duration of dysphagia, whether to liquids or solids, and whether there are associated features (reflux, odynophagia, weight loss, regurgitation). We determined odds ratio (OR) for these variables for the diagnoses of malignancy and peptic stricture. We determined the value of the Edinburgh Dysphagia Score (EDS) in predicting cancer in our cohort. Multivariate logistic regression was performed and P < 0.05 considered significant. The local ethics committee confirmed ethics approval was not required (audit).
The commonest diagnosis is gastro-esophageal reflux disease (41.3%). Malignancy (11.0%) and peptic stricture (10.0%) were also relatively common. Malignancies were diagnosed by histology (97%) or on radiological criteria, either sequential barium swallows showing progression of disease or unequivocal evidence of malignancy on computed tomography. The majority of malignancies were esophago-gastric in origin but ear, nose and throat tumors, pancreatic cancer and extrinsic compression from lung or mediastinal metastatic cancer were also found. Malignancy was statistically more frequent in older patients (aged >73 years, OR 1.1-3.3, age < 60 years 6.5%, 60-73 years 11.2%, > 73 years 11.8%, P < 0.05), males (OR 2.2-4.8, males 14.5%, females 5.6%, P < 0.0005), short duration of dysphagia (≤ 8 wk, OR 4.5-20.7, 16.6%, 8-26 wk 14.5%, > 26 wk 2.5%, P < 0.0005), progressive symptoms (OR 1.3-2.6: progressive 14.8%, intermittent 9.3%, P < 0.001), with weight loss of ≥ 2 kg (OR 2.5-5.1, weight loss 22.1%, without weight loss 6.4%, P < 0.0005) and without reflux (OR 1.2-2.5, reflux 7.2%, no reflux 15.5%, P < 0.0005). The likelihood of malignancy was greater in those who described true dysphagia (food or drink sticking within 5 s of swallowing than those who did not (15.1% vs 5.2% respectively, P < 0.001). The sensitivity, specificity, positive predictive value and negative predictive value of the EDS were 98.4%, 9.3%, 11.8% and 98.0% respectively. Three patients with an EDS of 3 (high risk EDS ≥ 3.5) had malignancy. Unlike the original validation cohort, there was no difference in likelihood of malignancy based on level of dysphagia (pharyngeal level dysphagia 11.9% vs mid sternal or lower sternal dysphagia 12.4%). Peptic stricture was statistically more frequent in those with longer duration of symptoms (> 6 mo, OR 1.2-2.9, ≤ 8 wk 9.8%, 8-26 wk 10.6%, > 26 wk 15.7%, P < 0.05) and over 60 s (OR 1.2-3.0, age < 60 years 6.2%, 60-73 years 10.2%, > 73 years 10.6%, P < 0.05).
Malignancy and peptic stricture are frequent findings in those referred with dysphagia. The predictive value for associated features could help determine need for fast track investigation whilst reducing service pressures.
确定哪些病史和人口统计学特征可预测因吞咽困难就诊的患者的恶性肿瘤或消化性狭窄的诊断。
对英国一所教学医院快速就诊吞咽困难服务的 2000 例连续转介患者（1031 名女性，年龄范围：17-103 岁）进行前瞻性病例对照研究，该服务包括护士主导的电话分诊，然后在 2 周内进行适当的调查（钡餐或胃镜检查）。对人口统计学和临床变量进行逻辑回归分析。这包括年龄、性别、吞咽困难持续时间、是液体还是固体、是否有相关特征（反流、咽痛、体重减轻、反流）。我们确定了这些变量对恶性肿瘤和消化性狭窄诊断的优势比（OR）。我们确定了爱丁堡吞咽困难评分（EDS）在我们的队列中预测癌症的价值。进行了多变量逻辑回归，P<0.05 认为有统计学意义。当地伦理委员会确认无需伦理批准（审核）。
最常见的诊断是胃食管反流病（41.3%）。恶性肿瘤（11.0%）和消化性狭窄（10.0%）也相对常见。恶性肿瘤通过组织学（97%）或影像学标准诊断，要么是连续钡餐显示疾病进展，要么是 CT 明确显示恶性肿瘤。大多数恶性肿瘤起源于食管-胃，但也发现了耳、鼻、喉肿瘤、胰腺癌和肺或纵隔转移性癌症的外压。在年龄较大的患者（>73 岁，OR 1.1-3.3，年龄<60 岁 6.5%，60-73 岁 11.2%，>73 岁 11.8%，P<0.05）、男性（OR 2.2-4.8，男性 14.5%，女性 5.6%，P<0.0005）、吞咽困难持续时间较短（≤8 周，OR 4.5-20.7，16.6%，8-26 周 14.5%，>26 周 2.5%，P<0.0005）、症状进行性加重（OR 1.3-2.6：进行性 14.8%，间歇性 9.3%，P<0.001）、体重减轻≥2kg（OR 2.5-5.1，体重减轻 22.1%，无体重减轻 6.4%，P<0.0005）和无反流（OR 1.2-2.5，反流 7.2%，无反流 15.5%，P<0.0005）的患者中，恶性肿瘤的可能性更大。那些描述真正吞咽困难（食物或饮料在吞咽后 5 秒内卡住）的患者比那些没有描述的患者（分别为 15.1%和 5.2%，P<0.001）恶性肿瘤的可能性更大。EDS 的灵敏度、特异性、阳性预测值和阴性预测值分别为 98.4%、9.3%、11.8%和 98.0%。3 名 EDS 为 3 分（高风险 EDS≥3.5）的患者有恶性肿瘤。与原始验证队列不同，根据吞咽困难的程度，恶性肿瘤的可能性没有差异（咽部水平吞咽困难 11.9%与中胸骨或下胸骨吞咽困难 12.4%）。消化性狭窄在症状持续时间较长的患者中更为常见（>6 个月，OR 1.2-2.9，≤8 周 9.8%，8-26 周 10.6%，>26 周 15.7%，P<0.05）和吞咽时间超过 60 秒（OR 1.2-3.0，年龄<60 岁 6.2%，60-73 岁 10.2%，>73 岁 10.6%，P<0.05）。
恶性肿瘤和消化性狭窄是因吞咽困难就诊的常见发现。相关特征的预测价值可以帮助确定需要快速跟踪调查，同时减轻服务压力。
