title: Can patients determine the level of their dysphagia?
abstract: OBJECTIVE
  To determine if patients can localise dysphagia level determined endoscopically or radiologically and association of gender, age, level and pathology.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  Patient perceived level of dysphagia is unreliable in determining actual level of obstructing pathology and should not be used to tailor investigations.
authors.affiliation: Hafiz Hamad Ashraf, Harry Richard Dalton, Carolyn Waters, Iain Alexander Murray, Departments of Gastroenterology, Royal Cornwall Hospital NHS Trust, Truro TR1 3LJ, United Kingdom.
authors.forename: Hafiz Hamad
authors.initials: HH
authors.lastname: Ashraf
authors.affiliation: Hafiz Hamad Ashraf, Harry Richard Dalton, Carolyn Waters, Iain Alexander Murray, Departments of Gastroenterology, Royal Cornwall Hospital NHS Trust, Truro TR1 3LJ, United Kingdom.
authors.forename: Joanne
authors.initials: J
authors.lastname: Palmer
authors.affiliation: Hafiz Hamad Ashraf, Harry Richard Dalton, Carolyn Waters, Iain Alexander Murray, Departments of Gastroenterology, Royal Cornwall Hospital NHS Trust, Truro TR1 3LJ, United Kingdom.
authors.forename: Harry Richard
authors.initials: HR
authors.lastname: Dalton
authors.affiliation: Hafiz Hamad Ashraf, Harry Richard Dalton, Carolyn Waters, Iain Alexander Murray, Departments of Gastroenterology, Royal Cornwall Hospital NHS Trust, Truro TR1 3LJ, United Kingdom.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Waters
authors.affiliation: Hafiz Hamad Ashraf, Harry Richard Dalton, Carolyn Waters, Iain Alexander Murray, Departments of Gastroenterology, Royal Cornwall Hospital NHS Trust, Truro TR1 3LJ, United Kingdom.
authors.forename: Thomas
authors.initials: T
authors.lastname: Luff
authors.affiliation: Hafiz Hamad Ashraf, Harry Richard Dalton, Carolyn Waters, Iain Alexander Murray, Departments of Gastroenterology, Royal Cornwall Hospital NHS Trust, Truro TR1 3LJ, United Kingdom.
authors.forename: Madeline
authors.initials: M
authors.lastname: Strugnell
authors.affiliation: Hafiz Hamad Ashraf, Harry Richard Dalton, Carolyn Waters, Iain Alexander Murray, Departments of Gastroenterology, Royal Cornwall Hospital NHS Trust, Truro TR1 3LJ, United Kingdom.
authors.forename: Iain Alexander
authors.initials: IA
authors.lastname: Murray
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D003680:Deglutition Disorders / Q000175:diagnosis*; D059026:Diagnostic Self Evaluation; D004935:Esophageal Diseases / Q000175:diagnosis*; D004945:Esophagoscopy; D004947:Esophagus / Q000473:pathology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010465:Perception; D011859:Radiography; D012189:Retrospective Studies; D012737:Sex Factors
keywords: Deglutition disorders; Fluoroscopy; Gastroscopy; Oesophageal neoplasm; Oesophageal stenosis; Patient perception; Pharyngeal pouch