Apporach to Dysphagia

And benign esophgeal diseases

Presented by;

Lina bani hamad

dysphagia - The physiology of swallowing

- Definition

- Epidemology

There are two forms of dysphagia

Oropharyngeal dysphagia (transfer dysphagia):

There's problem in initiating the swallowing occurs in

patients with neurologic conditions or muscular

disorders that affect skeletal muscles.

It will be associated with cough-ing, chocking, nasal

regurgitation

Esophageal dysphagia relates to intrinsic functional (motor) and anatomic abnormalities of the esophagus that result in swallowing difficulties.

May associated with history of food impaction and food sticking of the chest

Oropharyngeal dysphagia

Neurologic

• Stroke

• Parkinson's disease

• Multiple sclerosis

• motor neuron disorders (

progressive bulbar palsy,

pseudobulbar palsy) • Bulbar

poliomyelitis

Muscular

• Myasthenia gravis •

Dermatomyositis

• Muscular dystrophy •

Cricopharyngeal incoordination

Esophageal dysphasia

Motility disorder

• Achalasia

• Diffuse esophageal spasm

• Systemic sclerosis(scleroderma)

• Eosinophilic esophagitis

Mechanical obstruction

Peptic stricture

• Esophageal cancer

• Lower esophageal

rings(Schatzki's ring)

• Caustic ingestion

SIGNIFICANCE AND

COMPLICATIONS points to a serious underlying pathology

Aspiration can cause acute pneumonia

recurrent aspiration may eventually lead to chronic lung

disease.

inadequate nutrition and weight loss.

death

Apporach to the patient

-History age

Onset

Duration

Intermittent or progressive

Solids or liquids

Level of stuck

Odynophagia

Hx pf caustic ingestion ,GERD,PUD

Fever, weight loss,anorexia,fatigue

Immunocomprised pt (DM,steriods) why?

Chest pain ,cough (pneumoina)

Hx of neck mass

Hx of cardiac problems

Drugs (anticholingeric,doxycyclin)

Family hx

PHYSICAL EXAMINATION

General examination(nutritional status ,skin, lymph

nodes, signs of sleroderma

Neck examination

The abdomen is checked for masses, tenderness, and

organomegaly

complete neurologic examination

Muscles are inspected for wasting and fascicula- tions

and are palpated for tenderness (dermatomy-sitis,

myopathy).

Diagnostic Tests

the barium swallow is the ideal first test as it is readily available, cost effective, and rapidly performed.

anatomic relations, esophageal transit patterns, and the presence or absence of mass lesions and diverticula.

. Upper endoscopy allows for a visual assessment of mucosa after caustic ingestion or due to an infectious

etiology

Other tests for specific causes are done as sug-gested

by findings.

When reflux disease is suspected, extended pH monitoring is invaluable in assessing the presence and severity of GERD.

Motility disorders are best diagnosed using manometric techniques.

In cases where extrinsic compression is

suspected or demonstrated, cross-sectional imaging using computed tomography (CT) or magnetic resonance imaging (MRI) may be useful in identification of malignant masses or vascular anomalies (aberrant subclavian vessels, aortic aneurysms

Treatment

Treatment is directed at the specific cause.

emergent upper endoscopy If com-plete obstruction

occurs

careful endoscopic dilation is performed. If a stricture,

ring, or web is found

Patients with severe dysphagia and re-current aspiration

may require a gastrostomy tube.

Esophagus

eso

Anatomy 25 cm long. It has cervical

(5 cm), tho-racic (18 cm)

and abdominal (2 cm)

Blood supply

lymphatic drainge

PHYSIOLOGY

The main function of the esophegus is to transfer food

from the mouth to the stomach in a coordi-nated

fashion and prevents stomach acid and con-tent reflux

upward

USE: antaomical sphincter

LES: fuctional sphincter

Assessment of esophageal function:

Structural

-Radiology

-Endoscopy(rigid, flexible)

Functional

Stationary manometry

24 Hours pH monitoring

GERD:

it is chronic problem that occur when acid from the stomach washes up into the esophagus. it is a common dis-ease that accounts for approximately two thirds of esophageal pathology.

Common symptoms – esophageal crises

heartburn: substernal burning-type discomfort beginning in the epigastrium

and radiating upwards. Aggrevated post prandial, spicy,smoking

Regurgitation: The effortless return of acid or bitter gastric contents into the chest , pharynx or mouth.

Atypical symptoms – respiratory crises

Chest pain and dysphagia

Human antireflux mechanisms:

High pressure zone at GE junction

Specialized thickening

Collar sling and clasp fibres

Receptive relaxation

Association with HH:

Repeated gastric distension

GEJ ( upside down funnel-shaped )

Progressive opening of the angel of His )

Stretching of phrenico esophageal ligament

Enlargement of hiatal opening

Axial herniation

DIAGNOSIS

History

Barium study

a hiatus hernia, the presence of severe ulceration, benign

strictures

Endoscopy

confirm reflux if esophagitis is seen and allow taking

biopsies to detect complications (Barrett’s esophagus

24 Ph monitoring

the gold standard in establishing the diagno-sis of acid

reflux

GERD treatment:

High doses of PPIs

If symptoms return …….Endoscopy

Surgery:anti-reflux surgery - Nis-sen’s

fundoplication

Advice on:

Change of life style(advice against weight loss,

smoking, excessive consump-tion of alcohol, tea or

coffee.)

Dietary measures

25-50% persistent or progressive disease

Anti reflux Surgery:

create a new anti reflux valve at GEJ,while preserving

the patient ability to swallow normally and to belch to

relieve the gaseous distension.

( Nissen fundoplication)

COMPLICATIONS

BARRETT'S ESOPHAGUS Barretts esophagus (BE ):

10-20% of GERD

Defined as the presence of columnar mucosa extending at least 3 cms into the esophagus

Complicated by:

Ulceration

Stricture

Dysplasia-cancer sequence

Respiratory complications

Hiatus Hernias (HH ):

Types:

Sliding: type 1m.c

Para esophageal (PEH) Rolling type 11

Combined type111

Sliding is 7 times more than PEH

PEH are more in elderly women

Manifestations

Usually GERD in type 1

But in PEH ( pressure symptoms )

Significant incidence of catastrophic life-threatening

Complications risk of strangulations )

Diagnosis:

lateral Erect CXR; fluids above diaphragm in PEH

Barium study: determine which the type

Fiberoptic esophagoscopy

Treatment:

Life style changes

Surgery

Scleroderma:

80% of patients have esophageal motility

abnormalities

Result from vascular compromise due to

collagen deposition -Smooth muscle atrophy

In general Motility Disorders:

Manifested by dysphagia

Pain, chokes or vomits with eating,Require liquids

with eating,The last to finish

Diagnosis is by manometry

Zenkers Diverticulum:

Occur in proxmial part of esophagus

Elderly

Dysphagia with spontaneous regurge ( bland )

Repeated Respiratory tract infections Diagnosed by Barium swallow and endoscopy

Treated surgically by diverticulopexy or

diverticulectomy

acc to the size

Motility disorders of the esophagus:

Abnormalities in

Propulsive pump action

Relaxation of LES

Primary, or

Generalised:

Neural, Muscular, Collagen deposit

Four categories:

1. Achalasia

2. diffuse esophgeal spasms

3. Nutcracker esophagus

4. HH , lower esophgeal spasm

Achalasia:

Failure of lES to relax during propulsive foods –stick

foods in esophgus –dilation of proximal esophagus

Esophageal dilatation ( bird peak and air fluid level )

it is common 1 : 100 000

Treatment

involves either balloon dilatation of the

lower oesophageal sphincter

surgical myotomy (Hellers myotomy;

division of the muscles over the lower

esophagus and proximal stomach).

Diverticula of the esophagus

Location : in the body of the esophagus

May present with dysphagia or pressure symptoms

Pathophysiology ;

-Pulsion; increase in pressure in esophagus wall due to any

motilty disorders – push esophagus wall outside-true

divericula (zenker diverticulum)

- traction: normal esohagus wall

- The wall pulled outside by inflamed l.n in hilum of the

lung -TB

Thank you