Dysphagia

Associate Prof. Dr. Meltem Ergun

Yeditepe University

Department of Gastroenterology

Learning Objectives• What is dysphagia?• What are types of dysphagia?• What are the causes of

dysphagia?• How to investigate a patient

with dysphagia?• How is dysphagia treated?

• Difficulty in swallowing=dysphagia

• Dysphagia suggests the presence of an organic

abnormality in the passage of solids or liquids

from the oral cavity to the stomach.

• Patients' complaints range from the inability to

initiate a swallow to the sensation of solids or

liquids being hindered during their passage

through the esophagus into the stomach.

Dysphagia is an alarm symptom that warrants immediate evaluation to define the exact cause and initiate appropriate therapy. Dysphagia in older adult subjects should not be attributed to normal aging. Aging alone causes mild esophageal motility abnormalities, which are rarely symptomatic

The Normal Swallow

• Innate ability which is present in the developing fetus

• Necessary to maintain nutrition and hydration

• Adults swallow approximately 580 times daily unconsciously

• Swallowing is a four-phase process:– Oral preparatory phase– Oral phase– Pharyngeal phase– Esophageal phase

Oral Preparatory Phase• Begins as food or liquid enters the mouth

• Containing, manipulating, and preparing the food or liquid into a bolus

• Chewing (mastication) occurs to grind solid bolus into manageable texture– Requires coordination of lips, tongue, teeth, mandible,

and cheeks

• Duration: variable depending on substance

• Respiration: normal through the nose (mouth closed)

Oral Phase

• Bolus is propelled to the back of the

mouth– “stripping action” by the tongue

– Tension in the cheeks (buccal muscles)

• Duration: 1-1.5 seconds

• Respiration: normal through the nose

Pharyngeal Phase• Begins as the bolus reaches the tonsils (faucial pillars)

• Pharygeal swallow reflex is triggered:

– Pharyngeal wall and back of tongue move together and

pharyngeal muscles squeeze to move bolus down through the

pharynx

• Upper esophageal sphincter opens to allow passage of

bolus into esophagus

• Time: 1 second

• Respiration: briefly halted (apneic moment)

• During bolus transit, risk of food or liquid entering the

airway

Pharyngeal Phase – Protective Mechanisms

• Soft palate elevates to stop bolus from flowing upward into

nasal area

• Larynx moves forward and higher in the neck to reduce risk

of entrance into airway

• Epiglottis forms a cover over the larynx

• Vocal folds come together to close the entrance into the

larynx

• If material does enter the larynx, reflexive cough to expel it

will occur

Esophageal Phase

• Bolus is propelled through the esophagus by an involuntary wave or contraction

• Moves from the upper esophageal sphincter through the lower esophageal sphincter and into the stomach

• Time: 8-20 seconds, can be influenced by age (often increase in duration in elderly population)

• Respiration: normal through nose and mouth

Disordered Swallow: Dysphagia

• Impairment can occur in one, some, or all of the four phases of

swallowing

• Some persons have impairments that result in aspiration (food

or liquid moves below the level of vocal folds into the airway)

• Some persons have to alter their diet to control the

consistencies, but this can cause difficulty maintaining

hydration and nutrition

• Some persons require an enteral feeding tube for nutritional

maintenance

CLASSIFICATIONTwo distinct syndromes

Oropharyngeal dysphagia

Esophageal dysphagia

Produced by abnormalities affecting the finely tuned neuromuscular mechanism of the striated muscle of the mouth, pharynx, and UES

Caused by the variety of disorders affecting the smooth muscle esophagus

Oropharyngeal dysphagia • Oropharyngeal dysphagia is characterized by difficulty

initiating a swallow. Swallowing may be accompanied by coughing, choking, nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx.

• It is a transfer problem caused by – impaired ability to transfer food from mouth to upper

esophagus – impaired oral preparatory phase

• Clinical presentation:– food sticking in the throat– difficulty initiating a swallow– nasal regurgitation– coughing during swallowing– They may also complain of

• dysarthria • nasal speech because of associated muscle

weaknesses– Other Neurological clinical findings

Oropharyngeal Dysphagia

Neuromuscular•CVA

•Parkinson’s disease•MS

•Mysthania gravis•Muscular dystrophy

•Bulbar / pseudobulbar palsy

Abnormalities Causing Oropharyngeal Dysphagia• Local Structural Lesions

– Inflammatory • Pharyngitis• Abscess• Tuberculosis• Syphilis

– Neoplastic– Congenital webs– Plummer-Vinson syndrome

– Extrinsic compression • Thyromegaly• cervical spine hyperostosis• Lymphadenopathy

– Surgical resection of the oropharynx

Case Study 1

• 45-year old man diagnosed with ALS 18 months ago

• Unable to work, on a puree diet with thin liquids, has lost 10

kg in past two months, just recovered from severe

aspiration pneumonia

• Severe oral and pharyngeal dysphagia with aspiration

• What should be the treatment?

• 35- year-old woman

presented with dysphagia

• Lab: Hb 8,6 Fe: TIBC:

Ferritin:

Case Study 2

• Plummer Vinson

sd.

Esophageal Dysphagia

Motility disorders•Achalasia

•Diffuse oesophageal spasm•Chaga’s disease

Etiology Of Esophageal Dysphagia

Neuromuscular (Motility) Disorders

• Most common– Achalasia– Scleroderma– Diffuse esophageal spasm

• Other associated motility abnormalities– Nutcracker esophagus– Hypertensive lower esophageal

sphincter– Vigorous achalasia– Nonspecific esophageal dysmotility

• Other secondary motility disorders– Other collagen disorders– Chagas disease

Etiology Of Esophageal Dysphagia

Mechanical Lesions, Intrinsic

• Most common– Peptic stricture– Lower esophageal (Schatzki)

ring– Carcinoma

• Other– Esophageal webs– Esophageal diverticula– Benign tumors– Foreign bodies

• Dysphagia

• Odynophagia

• Globus• (pain in

swallowing=odinophagia)

• Globus= something in my

throat

History

• Duration

• Stable, intermittent,

progressive

• Speed of progression

• Liquids or solids

History

• Hx of drugs

• Tetracycline

• Alendronate (for

Osteoporosis)

• Kostic injury

Investigations

Diagnostic• Endoscopy

• Barium swallow

• Manometry

Staging• CT

• Diagnostic laparoscopy

• EUS

• Biopsies

• Dilatation

• Stenting / laser

ablation

Investigations for Staging• CT or MRI

• EUS

• Staging laparoscopy

Manometry-patients with no structural abnormality

on endoscopy

Normal Swallow

Oesophageal Motility Disorders Achalasia-Aetiology

• Idiopathic- 98 %–Primary–Secondary

• Familial–Associated with other congenital

defects• Associated with degenerative

neurological disease

Oesophageal Motility Disorders Achalasia - Symptoms

• Dysphagia – usually slowly

progressive

• Regurgitation

• Chest pain and dysphagia

• Reflux symptoms

Oesophageal Motility Disorders Achalasia-Manometric features

Normal to raised LOS resting pressures

LOS fails to relax to gastric baseline

Raised residual pressuresRaised oesophageal baseline

pressuresAbsent or chaotic low amplitude

simultaneous peristalsis

Achalasia Tracing

Oesophageal Motility disorders Achalasia-Treatment

• Pneumatic dilatatation– Risks– Patient selection

• Botox injection– Patient selection

• Surgery– Gastro-oesophageal reflux a

significant complication

OESOPHAGEAL MOTILITY DISORDERS

NUTCRACKER OESOPHAGUS• Most common cause of NCCP in those

patients with an oesophageal motility

disorder.

• Average distal pressures > 180 mm Hg.

• Peristalsis is normal so Ba studies

usually normal.

• 90% present with chest pain.

Normal Swallow

Nutcracker Oesophagus

OESOPHAGEAL MOTILITY DISORDERS

DIFFUSE ESOPHAGEAL SPASM• Intermittent dysphagia with

occasional chest pain 90% present

with chest pain. (Corkscrew esop)

• DES is characterized by the

findings of simultaneous

contractions greater than 30% of

water swallows, with the presence

of normal peristalsis.

– Other associated manometric findings

may include repetitive contractions (>2

peaks),

– Prolonged contractions (>6 s),

– High-amplitude contractions (>180 mm

Hg),

– Spontaneous contractions

DYSPHAGIACONCLUSIONS

• The symptom of dysphagia does not always

indicate a physical obstruction

• Oesophageal motility disorders account for the

majority of cases of dysphagia

• A normal endoscopy or Ba study does not

exclude a motility disorder - role of oesophageal

manometry

• Importance of mucosal biopsies of

macroscopically normal mucosa