DYSPHAGIA

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DYSPHAGIA
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Question 1

• A 51 yr.old female presented with a hx of
  dysphagia that has been progressively worsening
  for months. Initially dysphagia was for solids
  only but more recently it is for both solids and
  liquids.
• Which of the following studies will most likely
  establish the diagnosis
• EGD
• Barium swallow
• CT
• manometry

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Question-2

• A 52 year-old male executive c/o intermittent
  dysphagia which began 2 years ago. When he is
  eating, he has episodes of the sudden sensation
  of food sticking in his throat after he swallows,
  lower chest discomfortand hypersalivation. On two
  occassions the discomfort has caused him to
  regurgitate undigested food. There is now wt
  loss.Physical exam is normal
• The most likely diagnosis is
• Achalasia
• Diffuse esophageal spasm
• Esophageal ring
• Peptic stricture
• Adenocarcinoma

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INTRODUCTION

• Dysphagiadifficulty with swallowingis a common
  condition, reported by 58 of the general
  population aged over 50 years, and by 16 of the
  elderly.
• Dysphagia, particularly oropharyngeal dysphagia,
  is even more common in the chronic-care setting
  up to 60 of nursing-home occupants have feeding
  difficulties that include dysphagia.

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ESOPHAGEAL ANATOMY
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ESOPHAGEAL ANATOMY
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SWALLOWING

• Mechanism is complex
• Involves the actions of 26 muscles and 5 cranial
  nerves
• CN V -- both sensory and motor fibers important
  in chewing
• CN VII -- both sensory and motor fibers
  important for sensation of oropharynx taste to
  anterior 2/3 of tongue
• CN IX -- both sensory and motor fibers important
  for taste to posterior tongue, sensory and motor
  functions of the pharynx
• CN X -- both sensory and motor fibers important
  for taste to oropharynx, and sensation and motor
  function to larynx and laryngopharynx important
  for airway protection
• CN XII -- motor fibers that primarily innervate
  the tongue
• A normal adult swallows unconsciously 600 times
  in a 24-hour period

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Esophageal Anatomy

• Upper one-third is composed of skeletal muscle
• Distal two-thirds is smooth muscle
• NO SEROSA
• Outer longitudinal, inner circular muscle layer
• Myenteric plexus of Auerbach, parasympathetic
  ganglion cells, interspersed among the muscle
  layers
• Submucosa blood vessels/lymphatics, myenteric
  plexus of Meissner (parasympathetic ganglion
  cells)
• Mucosa stratified squamous epithelium

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REVIEW

• The outermost collection, lying between the inner
  circular and outer longitudinal smooth-muscle
  layers of the gut, is called the myenteric (or
  Auerbach's) plexus.
• Neurons of this plexus regulate the peristaltic
  waves, consisting of polarized muscular activity,
  that move digestive products from oral to anal
  openings.
• In addition, myenteric neurons control local
  muscular contractions that are responsible for
  stationary mixing and churning.
• The innermost group of neurons is called the
  submucosal (or Meissner's) plexus. This group
  regulates the configuration of the luminal
  surface, controls glandular secretions, alters
  electrolyte and water transport, and regulates
  local blood flow

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Swallowing Stage 1

• Oral
• Food ingested, prepared (mastication) and
  modified (lubrication)
• Voluntary control
• Frequently results from weakness lips, tongue,
  cheeks
• Unable to organize food into well formed bolus
  and move posteriorly
• Xerostomia difficulty breaking down solids

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Swallowing Stage 2

• Pharyngeal
• Prevented from entering nasopharynx, larynx
  rises, retroflexion of epiglottis and vocal fold
  closure, synchronized contraction of middle and
  inferior constrictors, and synchronized
  relaxation of the cricopharyngeal muscle
  Involuntary
• Timing neurologic epiglottis doesnt protect
  larynx - leads to cough/aspiration
• Weakness neurologic injury/cancer residual
  food after swallow can lead to aspiration

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Stage 3

• Esophageal
• Begins with crico-pharyngeal relaxation
• Involuntary
• Most common
• Sensation of food sticking at base of
  throat/chest
• Peristalsis, tumor, stricture

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HISTORY

• Taking a careful history is vital for the
  evaluation of dysphagia.
• The history will yield the likely underlying
  -pathophysiologic process
  -anatomic site of the problem in most
  patients-80
  -crucial for determining whether
  subsequently detected radiographic or
  endoscopic 'anomalies' are relevant or
  incidental..

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HISTORY

• Three fundamental aims should be met when taking
  a dysphagia history.
• -The first is to establish whether or not
  dysphagia is actually present that is, to
  distinguish true dysphagia from globus
  sensation (in b/w meals), xerostomia-loose
  the lubrication properties and stimulus odynophag
  ia-transient than dysphagia, and persists only
  during the 1530 s that a bolus takes to
  traverse the esophagus.
• -The second is to determine whether the site of
  the problem is esophageal or pharyngeal
• -The third is to distinguish a structural
  abnormality from a motor disorder These avenues
  of enquiry are outlined below in an order that
  corresponds to that of a highly effective
  diagnostic algorithm.
• The history will also dictate whether the next
  diagnostic procedure should be endoscopy, a
  barium swallow or esophageal manometry. In some
  difficult cases, all three diagnostic techniques
  may need to be performed to establish an accurate
  diagnosis.

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Where is the site of bolus hold-up?

• Retrosternal bolus hold-up indicates that the
  disorder lies within the esophagus.
• However, the patient's perception of an apparent
  bolus hold-up in the neck has low diagnostic
  specificity, and cervical localization per se
  does not help the clinician to distinguish
  pharyngeal from esophageal causes of dysphagia.
• Owing to viscerosomatic referral, in 30 of cases
  the perceived site of hold-up is above the
  suprasternal notch when the actual hold-up is
  within the esophageal

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Does the patient report symptoms that are
predictive of oropharyngeal dysfunction

• there are four symptoms that have high
  specificity for oropharyngeal dysfunction
  -delayed or absent oropharyngeal swallow
  initiation -deglutitive postnasal
  regurgitation or egress of fluid
  through the nose during swallowing
  -deglutitive cough indicative of aspiration and
  -the need to swallow repetitively to achieve
  satisfactory clearance of swallowed
  material from the hypopharynx.
• If one or more of these four symptoms are present
  then the cause of dysphagia is probably
  oropharyngeal, either structural or neuromyogenic

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OROPHARYNGEAL VS ESOPHAGEAL
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Etiology of oropharyngeal dysphagia. 

• Structural
•   Tumor
•   Stenosis
• Postsurgical
• Radiation
• Idiopathic
•   Zenker's diverticulum
•   Cricopharyngeal bar
•   Web
•   Extrinsic compression
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• Neuromyogenic
•   Stroke
•   Head trauma
•   Parkinson's disease and parkinsonism
•   Amyotrophic lateral sclerosis
•   Multiple sclerosis
•   Myasthenia gravis
•   Myopathies (inflammatory, metabolic)

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ESOPHAGEAL

• Structural disorders
• Inflammatory and/or fibrotic strictures
• Peptic
• Caustic
• Pill-induced
• Radiation-induced
• Mucosal rings and webs
• Schatzki's ring
• Multiringed esophagus (eosinophilic
  esophagitis)
• Carcinoma
• Primary (squamous, adenocarcinoma)
• Secondary (e.g. breast, melanoma)

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• Disorders related to systemic diseases
• Pemphigus and pemphigoid conditions
• Lichen planus
• Scleroderma (multifactorial)
• Intramural lesions
• Leiomyoma
• Granular cell tumor
• Extramural lesions
• Aberrant right subclavian artery (dysphagia
  lusoria)
• Mediastinal masses
• Bronchial carcinoma
• Anatomical abnormalities
• Hiatal hernia
• Esophageal diverticulum

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• Motility disorders
• Achalasia and achalasia-like disorders
• Idiopathic (classic) achalasia
• Atypical disorders of lower esophageal
  sphincter relaxation
• Chagas disease
• Pseudoachalasia

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ESOPHAGEAL

• Differntiation mechanical vs motility
  disorder?

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Is the dysphagia for solids or liquids

• Patients who have a motor disorder will describe
  dysphagia for liquids and solids,
• Whereas patients who have structural disorders
  will describe dysphagia for solids only.
• Once a solid bolus becomes impacted, the patient
  will report dysphagia for liquids and solids,

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Motility- features

• Three cardinal features of dysmotility
  dysphagia (for solids and liquids), chest
  pain and
  regurgitation.
• Regurgitation during meals, as well as
  spontaneous regurgitation between meals or at
  night, is highly suggestive of dysmotility.
• Unlike regurgitation that is related to GERD,
  the regurgitated fluid in patients with
  esophageal dysmotility is generally not noxious
  to taste.
• In addition, spasm or achalasia typically cause
  chest pain. Although this chest pain is
  frequently described as 'heavy' or 'crushing', it
  can be indistinguishable from the typical
  'heartburn' of reflux.
• The pain frequently occurs during meals, but it
  can be quite unpredictable and sporadic or
  nocturnal.
• Sipping antacids or even water can relieve the
  pain related to dysmotility, which further
  confuses its distinction from reflux-related pain.

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How long has dysphagia been present? Is it
intermittent? Is it progressive?

• Slowly progressive, long-standing dysphagia,
  particularly against a background of reflux, is
  suggestive of a peptic stricture.
  Caveat -severity of heartburn correlates
  poorly with esophageal mucosal damage. For
  example, patients who have severe mucosal
  changes, including strictures and Barrett's
  mucosa, could have had minimal or no heartburn in
  the immediate past.
• A short history of dysphagiaparticularly with
  rapid progression (weeks or months) and
  associated weight lossis highly suggestive of
  esophageal cancer.
• Long-standing, intermittent, nonprogressive
  dysphagia purely for solids is indicative of a
  fixed structural lesion such as a distal
  esophageal ring or proximal esophageal mucosal
  web.

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Examination of the patient with dysphagia

• The physical examination is generally
  unremarkable.
• Skin should be examined for features of
  connective tissue disorders, particularly
  scleroderma and CREST (calcinosis, Raynaud's
  phenomenon, esophageal dysmotility, sclerodactyly
  and telangiectasia) syndrome.
• Muscle weakness or wasting might be evident if
  myositis is present, and myositis can overlap
  with other connective tissue disorders that
  affect the esophagus.
• Signs of malnutrition, weight loss and pulmonary
  complications from aspiration should be looked
  for.
• If pharyngeal dysphagia is suspected, evaluation
  for neuromuscular disorders is important

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Investigation of esophageal dysphagia

• Barium swallow study,
• Endoscopy and
• Esophageal manometry.

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NO DYSPHAGIA
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INTERMITTENT DYSPHAGIA FOR SOLIDS
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DYSPHAGIA WITH LONG HX OF GERD
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Bulge in the left side of the neck while eating
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DYSPHAGIA FOR SOLIDS AND LIQUIDS WITH WT LOSS
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DYSPHAGIA FOR SOLIDS AND LIQUIDS
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young male patients who present with intermittent
dysphagia or bolus impaction
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INTERMITTENT DYSPHAGIA FOR SOLIDS AND LIQUIDS

• Numerous nonpropulsive contractions
• corkscrew/ rosary bead esophagus

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INTERMITTENT DYSPHAGIA FOR SOLIDS
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IRON DEFIIENCY ANEMIA
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Due to an aberrant right subclavian artery
coursing posterior to esophagus
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