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Dysphagia

• Dr. Hamid Kalantari
• Isfahan university of medical sciences

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Esophagus ?? ???? ?????? ????? ?? ?????

• The upper esophageal sphincter (UES)
• The esophageal body
• The lower esophageal sphincter (LES)

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Physiology of swallowing

• Voluntary Oral phase
• Involuntary pharyngeal and
• esophageal phase
• (deglutition Reflex)
  
• Primary peristaltism
• Secondary peristaltism
• Tertiary contractions

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Dysphagia

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

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Dysphagia should be distinguished from

• Aphagia
• Odynophagia
• Globus pharyngeous

• Phagophobia
• hysteria
• rabies
• tetanus
• pharyngeal
• paralysis

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Pathophysiology of Dysphagia

• Size of the ingested bolus
• The luminal diameter
• The force of peristaltic contraction
• Deglutive inhibition
• normal relaxation of upper and
• lower esophageal phincters during
• swallowing

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Classification of Dysphagia

• Mechanical
• Motor

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Mechanical Dysphagia

• Luminal
• A-large bolus
• B- Foreign body
• Intrinsic narrowing
• Esophagitis
• Web, rings
• Benign stricture
• Malignant tumor
• Benign tumor

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• Extrinsic Compression
• Cervical Spondylitis
• Vertebral Osteophytes
• Retropharyngeal abscess and Masses
• Thyromegaly
• Zenkers diverticulum
• Vascular Compression
• Posterior mediastinal masses
• Pancreatic tumor, Pancreatitis
• Postvagotomy hematoma and Fibrosis

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Motor Dysphagia

• Pharyngeal paralysis
• Cricopharyngeal Achalasia
• Scleroderma of the esophagus
• Diffuse esophageal spasm

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Approach to the patient with dysphagia

• History 80
• Barium swallow
• Endoscopy
• Manometry
• PH metry

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Algorithm for the differential diagnosis of
dysphagia
Dysphagia
Food stops or sticks after swallowed
Difficulty initiating swallows (includes
coughing. choking. and nasal regurgitation)
Oropharyngeal dysphagia
Esophageal dysphagia
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Algorithm for the differential diagnosis of
dysphagia
Esophageal dysphagia
Solid food only
Solid and liquid food
Neuromuscular disorder (Motor)
Mechanical obstruction
Intermittent
Progressive
Intermittent
Progressive
Bread/steak
Chronic heartburn No weight loss
Chronic heartburn
Age gt 50 Weight loss
Chest pain
Blandregurgitation Weight loss
Achalasia
Scleroderma
Carcinoma
Lower esophageal ring
Peptic Stricture
Diffuse esophageal spasm
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Esophageal motor Disorders Esophageal motor Disorders Esophageal motor Disorders Esophageal motor Disorders
Achalasia Scleroderma Diffuse Esophageal Spasm
symptoms Dysphagia Gastroesophageal reglux disease Substernal chest pain (anginalike)
symptoms Regurgitation of nonacidic material Gastroesophageal reglux disease Substernal chest pain (anginalike)
symptoms Regurgitation of nonacidic material Dysphagia Dysphagia with pain
symptoms Regurgitation of nonacidic material Aperistaltic esophagus Simultaneous noncoordi- nated contractions
X- ray appearance Dilated, fluid- filled esophagus Aperistaltic esophagus Simultaneous noncoordi- nated contractions
X- ray appearance Distal bird beakstricture Aperistaltic esophagus Simultaneous noncoordi- nated contractions
X- ray appearance Distal bird beakstricture Free reflux Simultaneous noncoordi- nated contractions
X- ray appearance Distal bird beakstricture Peptic stricture Simultaneous noncoordi- nated contractions
Manometric findings lower esophageal sphincter High resting pressure Incomplete or abnormal re- laxation with swallow Low resting pressure Normal pressure
body High resting pressure Incomplete or abnormal re- laxation with swallow Low resting pressure Normal pressure
body Low- amplitude, simultaneous contractions after swallow Low- amplitude peristaltic contractions or no peristasis Some peristalsis
body Low- amplitude, simultaneous contractions after swallow Low- amplitude peristaltic contractions or no peristasis Diffuse and simultaneous nonperistaltic contractions, occasionally high amplitude