Seminar Presentation

DYSPHAGIA

Ahmad al quran

Definition

The term dysphagia, derived from the Greek “dys” (with difficulty) and “phagia” (to eat), describes difficulty in the transfer of food or liquid boluses

from the mouth to the stomach

Types of Dysphagia

There are two forms of dysphagia.

Oropharyngeal dysphagia results from a functional impairment in the initiation of swallowing, including the oral

and pharyngeal phases and often results from systemic neurologic or myopathic syndromes.

Esophageal dysphagia relates to intrinsic functional

(motor) and anatomic abnormalities of the esophagus that result in swallowing difficulties.

Important Elements to elicit on history

Dysphagia ofTiming

Immediate coughing, choking, or regurgitation suggests oropharyngeal causes for dysphagia.

A sensation of food “sticking” or getting “caught” or the

delayed regurgitation of food suggests esophageal causes of dysphagia.

Patients reporting the constant presence of symptoms not

globus associated with swallowing difficulties may have the neck in fullness which is a benign, non painful , sensation

or throat.

History taking – Important Point

Swallowing Painful

Odynophagia is not typically associated with dysphagia; its presence should prompt consideration of infectious or

inflammatory etiologies.

Location

Patients will self-localize symptoms to the cervical, retrosternal, or epigastric regions

History taking – Important Points

Liquid Solid or

Intolerance to both liquids and solids suggests a functional or neuromuscular cause of dysphagia.

Difficulties with solid food only strongly implicates a

mechanical or anatomic causes of dysphagia;

.

History taking – Important Points

Progression andOnset

intrinsic an symptoms suggest Intermittent, nonprogressive

or a spasm) (such as diffuse esophageal motor dysfunction mechanical cause such as a web or ring.

time of period short for a the symptoms have been present If

ruled must be rapidly progressive, a malignant etiologyor are out.

History taking

Symptoms Associated A history of anorexia or weight loss suggests an underlying

malignancy.

Passive regurgitation of food particles may arise from achalasia or a

cricopharyngeal diverticulum.

Retrosternal chest pain, once cardiac etiologies have been

eliminated, may be present in cases of esophageal spasm or gastroesophageal reflux.

History Taking

History Drug

alendronate,

doxycycline,

nonsteroidal anti-inflammatory drugs [NSAIDs]

These may cause drug-induced esophageal injury and hence

dysphagia

Physical Examination

The head and neck are examined for the size of the thyroid gland, as well as for the presence of any

lymphadenopathy or masses.

A careful examination of cranial nerves may demonstrate deficits contributing to oropharyngeal

dysphagia, and corresponding neurologic assessment may reveal signs of a cerebrovascular accident

(CVA), myasthenia gravis, or Parkinson disease.

Diagnostic Tests

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

Information can be gained from the barium study regarding anatomic relations, esophageal transit

patterns, and the presence or absence of mass lesions and diverticulae.

The safety and diagnostic yield of subsequent upper endoscopy are enhanced.

UGI Endoscopy

Upper endoscopy allows for a visual assessment of mucosa;

biopsies, as such maneuvers therapeuticand diagnostic

brushings, and dilatations can be performed.

Diagnostic Tests

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

Dysphagia lusoria

which in entity is a rare Dysphagia lusoriadysphagia results from extrinsic vascular

right aberrant an compression of the esophagus from , which arises from the thoracic subclavian artery

aorta and typically courses posterior to the esophagus.

Diagnostic Tests

The assessment of esophageal cancer also requires cross-sectional imaging with CT and –positron

emission tomography (PET).

Management of Esophageal Dysphagia

functional disorders

Motility disorders affect the smooth muscle of the distal

esophagus and the lower esophageal sphincter (LES). Symptoms typically include dysphagia to solids and liquids;

non cardiac chest pain may also be present.

B R I E F O V E R V I E W

PrimaryDysmotility disordres

B R I E F O V E R V I E W

Achalasia

Achalasia

is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Ninety-eight percent of all cases of achalasia are idiopathic.

The disease is thought to result from a loss of inhibitory neurons in the Auerbach plexus, altering neural input to the LES and preventing normal relaxation.

Achalasia affects females and males equally at a rate of1 per100,000 individuals per year.

The usual presentation is between20 and50 years but it has been described in all age groups

Symptoms - Achalasia

Symptoms include progressive dysphagia to both solids and liquids, accompanied by regurgitation of

food particles, chest pain, and weight loss.

GERD-like symptoms were present in up to48% of

patients; these symptoms are a consequence of stasis esophagitis (secondarily to fermentation of

retained food) rather than reflux of gastric acid.

Plain x-rays may reveal an air-fluid level in the distal esophagus, and a barium swallow will demonstrate

a dilated and atonic esophagus with the pathognomonic “bird’s beak” narrowing of the

gastroesophageal junction (GEJ).

Long-standing achalasia may manifest with an

extremely dilated and tortuous esophagus (often described as a sigmoid esophagus).

diagnosis

diagnosis

Esophageal manometry:the defenitive diagnostic test for achalasia Manometric findings: absent perstalsis and failure of LES relaxation are key in establishing the diagnosis.

Resting LES pressures may be normal or elevated.

Endoscopic assessment is required to visually assess mucosal appearance to rule out cancer.

Barium swallow demonstrates the proximal dilatation and

classic “bird’s beak” narrowing at the esophagogastric

junction, consistent with achalasia, in a 22- year-old woman being evaluated for

dysphagia.

Barium study demonstrates dilated esophagus with right-

sided deviation and tortuous course of the

distal esophagus.

Treatment Modalities

Medical management with calcium channel

blockers or nitrates has no meaningful benefit.

Endoscopic management includes endoscopically

injected botulinum toxin, or balloon dilatation, to mechanically disrupt the lower esophageal muscle fibers.

Recurrent dysphagia (up to 50%) has been noted in some studies at 5 years after balloon dialtation with a 5% periprocedural risk of esophageal rupture.

In comparison a laproscopically performed “heller

esophagomyotomy”is considered to be the standard of

care in terms of both durable outcomes and low

complication rates.

Long-standing achalasia is a risk factor for esophageal squamous cell carcinoma, and tumors of the GEJ may present with symptoms similar to those of achalasia

complications

Diffuse Esophageal Spasm

DES is a dysmotility syndrome of unknown etiology. is characterized by loss of the normal per-

istaltic coordination of the esophageal smooth muscle. This results in simultaneous contraction of segments of the esophageal body.

symptoms

1-severe spastic pain, which can occur spontaneously and at night. 2-dysphagia 3-regurgitation

Barium swallow: corkscrew appearance Esophageal manometry:

periodic prolonged

multipeaked, high-amplitude contractions in more than one in five wet swallows, with observation of normal peristalsis in intervening periods.

Incomplete LES relaxation or hypertensive LES may also be observed.

diagnosis

DES

The classic corkscrew appearance of the esophagus is

evident in this barium study in a middle-aged patient presenting

with dysphagia and intermittent chest pain.

Nutcracker Esophagus

Nutcracker esophagus presents more commonly with chest pain rather than dysphagia.

Manometry also forms the mainstay of diagnosis:, with

extremely increased pressure amplitudes of more than180mm Hg.

In contrast to DES, normal peristalsis is not observed

within trains of high-pressure waves.

Barium swallow is of normal appearance

Hypertensive LES

Hypertensive LES may be found in isolation but often coexists with other dysmotility

syndromes.

Resting pressures at the LES by manometry are

found to be45 mm Hg or greater.

Treatment

Treatment for DES, nutcracker esophagus, and hypertensive LES is based on smooth muscle relaxation using nitrates such as isosorbide dinitrate or calcium channel blockers such as diltiazem.

Balloon dilatation may be effective for isolated

hypertensive LES.

B R I E F O V E R V I E W

secondary dysmotility disorders

Secondary Motor Disorders

In secondary dysmotility syndromes, the esophageal symptoms are a manifestation of a generalized

systemic process.

The etiology is thought to be progressive neuropathy and subsequent fibrosis.

Common diseases associated with secondary dysmotility include:

Rheumatologic syndromes, such as scleroderma, and

Diabetes mellitus

B R I E F O V E R V I E W

Mechanical Obstruction

Webs

A web is a thin mucosal fold that protrudes into the esophageal lumen.

Congenital webs are rare and usually restricted to the

pediatric population.

These are located in the middle and lower thirds of the

esophagus.

Acquired webs are normally located in the postcricoid

cervical esophagus and are mostly asymptomatic.

Etiologies for acquired webs include iron deficiency anemias (Plummer-Vinson and Paterson-Kelly

syndromes) and dermatologic diseases.

Webs are twice as common in female patients. Plummer–Vinson syndrome is a rare disease characterized by difficulty swallowing, iron-deficiency anemia, glossitis and esophageal webs

Symptoms

Dysphagia occurs intermittently with solids

Treatment

Diagnosis is by barium swallow and esophageoscopy to exclude malignancy , and treatment involves mechanical dilatation

.balloons or endoscopic bougies Savary using

Underlying anemias and dermatologic conditions

should also undergo assessment and appropriate treatment

Savary dialator

Rings

Esophageal rings are typically located in the lower third of the esophagus.

Two types are typically described: Muscular rings and

Mucosal or Schatzki rings.

Muscular rings are rarely associated with dysphagia and are often found incidentally in children

undergoing barium swallow for other reasons.

Schatzki Rings

Schatzki rings are located at the Z-line (squamo- columnar junction) and are almost always seen in patients with GERD; consequently, the upper surface of a Schatzki ring is covered by squamous epithelium, whereas the lower surface is covered by columnar epithelium.

Associations with eosinophilic esophagitis and GERD have been proposed. Diagnosis and treatment are as for esophageal webs.

ring Schatzki

Barium swallow demonstrates a ring

in a middle-aged man with severe

gastroesophageal reflux disease

symptoms and recent-onset

dysphagia

Peptic Stricture

benign esophageal stricture, or peptic stricture, is a narrowing or tightening of the esophagus that

causes swallowing difficulties

Peptic stricture was previously found in up to10% of patients with GERD and represents the end stage of

reflux associated ulcerative esophagitis.

Symptoms are described as progressive in nature and involve initial solid food dysphagia, progressing

to liquid dysphagia.

evaluation

Initial assessment is by barium swallow. Esophagoscopy is essential to assess the location, length, size, and distensibility of the stricture and to obtain appropriate biopsies or brush-

Ings to exclude malignancy.

.

Peptic Strictures

Treatment includes acid suppression and endoscopic

dilatation.

Conclusion

Evaluation of the patient presenting with dysphagia represents a challenge for the surgeon.

A careful history is key in determining likely etiologies.

be the first diagnostic should swallowbarium The test to be considered, endoscopy to follow.

represents the gold manometryEsophageal standard for diagnosing benign, functional (motor)

disorders.

Treatment is varied and depends on the etiology of the dysphagia.

references

the washington manual of surgery 8th edition

Thank You