نام به خدا

DysphagiaDysphagia

Dr. Hamid Kalantari Dr. Hamid Kalantari

Isfahan university of medical sciences Isfahan university of medical sciences

Esophagus Esophagus دارای عضالنی لوله دارای یک عضالنی لوله یک

منطقه منطقه سه : :سهThe upper esophageal sphincter (UES) The upper esophageal sphincter (UES) The esophageal body The esophageal body The lower esophageal sphincter (LES) The lower esophageal sphincter (LES)

Physiology of swallowingPhysiology of swallowing

Voluntary: Oral phase Voluntary: Oral phase Involuntary: pharyngeal and Involuntary: pharyngeal and

esophageal phase esophageal phase

(deglutition Reflex) (deglutition Reflex) Primary peristaltism Primary peristaltism Secondary peristaltism Secondary peristaltism Tertiary contractions Tertiary contractions

DysphagiaDysphagia

Sensation of sticking or Sensation of sticking or obstruction of the passage of food obstruction of the passage of food through the mouth , pharynx or through the mouth , pharynx or

esophagus.esophagus.

Dysphagia should be Dysphagia should be distinguished from:distinguished from:

Aphagia Aphagia Odynophagia Odynophagia Globus Globus

pharyngeouspharyngeous

Phagophobia Phagophobia

hysteria hysteria

rabies rabies

tetanustetanus

pharyngealpharyngeal

paralysis paralysis

Pathophysiology of Pathophysiology of DysphagiaDysphagia

Size of the ingested bolus Size of the ingested bolus The luminal diameter The luminal diameter The force of peristaltic contraction The force of peristaltic contraction Deglutive inhibition: Deglutive inhibition:

normal relaxation of upper andnormal relaxation of upper and

lower esophageal phincters duringlower esophageal phincters during

swallowing swallowing

Classification of Classification of DysphagiaDysphagia

Mechanical Mechanical Motor Motor

Mechanical Mechanical DysphagiaDysphagia I.I. Luminal Luminal

A-large bolus A-large bolus B- Foreign body B- Foreign body

II.II. Intrinsic narrowingIntrinsic narrowing

A.A. Esophagitis Esophagitis B.B. Web, rings Web, rings C.C. Benign stricture Benign stricture D.D. Malignant tumor Malignant tumor E.E. Benign tumor Benign tumor

III.III. Extrinsic CompressionExtrinsic Compression

A.A. Cervical Spondylitis Cervical Spondylitis

B.B. Vertebral Osteophytes Vertebral Osteophytes

C.C. Retropharyngeal abscess and Masses Retropharyngeal abscess and Masses

D.D. Thyromegaly Thyromegaly

E.E. Zenker`s diverticulumZenker`s diverticulum

F.F. Vascular Compression Vascular Compression

G.G. Posterior mediastinal massesPosterior mediastinal masses

H.H. Pancreatic tumor, Pancreatitis Pancreatic tumor, Pancreatitis

I.I. Postvagotomy hematoma and Fibrosis Postvagotomy hematoma and Fibrosis

Motor DysphagiaMotor Dysphagia Pharyngeal paralysis Pharyngeal paralysis Cricopharyngeal AchalasiaCricopharyngeal AchalasiaScleroderma of the Scleroderma of the

esophagusesophagusDiffuse esophageal spasm Diffuse esophageal spasm

Approach to the Approach to the patient with patient with dysphagiadysphagia

History : 80%History : 80%Barium swallowBarium swallow

EndoscopyEndoscopy

ManometryManometry

PH metry PH metry

Algorithm for the differential diagnosis of Algorithm for the differential diagnosis of dysphagiadysphagia

Dysphagia

Difficulty initiating swallows (includes coughing. choking. and nasal regurgitation)

Food stops or “sticks”

after swallowed

Oropharyngeal dysphagia

Esophageal dysphagia

Algorithm for the differential diagnosis Algorithm for the differential diagnosis of dysphagiaof dysphagia

Esophageal dysphagia

Solid food only

Solid and liquid food

Mechanical obstruction

Neuromuscular disorder (Motor)

Intermitt

ent Progressive

Bread/steak

Lower esophageal ring

Chronic heartburn

No weight loss

Age > 50

Weight loss

Peptic Stricture

Carcinoma

Intermittent

Progressive

Chest pain

Diffuse esophagealspasm

Chronic heartburn

Scleroderma

Blandregurgitation

Weight loss

Achalasia

Esophageal motor DisordersEsophageal motor Disorders

Achalasia Achalasia SclerodermaScleroderma

Diffuse Esophageal Diffuse Esophageal

SpasmSpasm

symptomssymptoms DysphagiaDysphagia Gastroesophageal Gastroesophageal reglux diseasereglux disease

Substernal chest pain Substernal chest pain (anginalike)(anginalike)Regurgitation of nonacidic Regurgitation of nonacidic

material material Dysphagia Dysphagia Dysphagia with pain Dysphagia with pain

Aperistaltic Aperistaltic esophagus esophagus

Simultaneous noncoordi-Simultaneous noncoordi-

nated contractions nated contractions

X- ray X- ray appearanceappearance

Dilated, fluid- filled esophagusDilated, fluid- filled esophagus

Distal “bird beak”strictureDistal “bird beak”stricture

Free reflux Free reflux

Peptic stricture Peptic stricture

Manometric Manometric findingsfindings

lower esophageal lower esophageal

sphinctersphincter High resting pressure High resting pressure Incomplete or abnormal re- Incomplete or abnormal re- laxation with swallow laxation with swallow

Low resting pressure Low resting pressure Normal pressure Normal pressure

bodybody Low- amplitude, simultaneous Low- amplitude, simultaneous contractions after swallowcontractions after swallow Low- amplitude Low- amplitude

peristaltic peristaltic

contractions or no contractions or no peristasis peristasis

Some peristalsisSome peristalsis

Diffuse and simultaneous Diffuse and simultaneous nonperistaltic contractions, nonperistaltic contractions, occasionally high occasionally high amplitude amplitude