Approach%20to%20the%20patient%20with

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• Approach to the patient with
• Dysphagia
• Dr Ehsani
• Gastroenterologist/internist

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Dysphagia

• Definition sensation of sticking or obstruction
  of the passage of food through the
  mouth ,pharynx,or esophagus.
• Aphagia
• Odynophagia
• Phagophobia
• Feeling of fullness in the epigastrium

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Dysphagia

• Dysphagia is a subjective sensation
  that suggests the presence of an organic
  abnormality in the passage of liquids or solids
  from the oral cavity to the stomach.
• Dysphagia is considered to be an alarm
  symptom,indicating the need for an immediate
  evaluation to define the exact cause and initiate
  appropriate therapy.

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Dysphagia

• Dysphagia in elderly subjects should not be
  attributed to normal aging.
• Aging alone causes mild esophageal motility
  abnormalities,which are rarely symptomatic.

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Dysphagia

• The normal transport of an ingested bolus
  through the swallowing passage depends on the
  size of the ingested bolus,the luminal diameter
  of the swallowing passage , the force of
  peristaltic contraction,the deglutitive
  inhibition,including normal relaxation of UES,LES
  during swallowing

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Dysphagia

• Classification
• Mechanical (large bolus,luminal narrowing)
• Motor (weakness of peristaltic contractions
  ,impaired deglutitive inhibition causing
  nonperistaltic contractions , impaired sphincter
  relaxation)

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Dysphagia

• classification
• Oropharyngeal dysphagia
• Esophageal dysphagia
• Functional dysphagia

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Dysphagia

• Medical history
• the cornestone of evaluation
• Distinguish from odynophagia globus sensation
• Determine the types of food that produce
  symptoms
• Progressive or intermitent symptoms
• Others symptoms or findings

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Approach to the patient with dysphagia
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Dysphagia,esophagealDifferential diagnosis

• Peptic stricture
• in 10 of patients with GERD ,in older age, male
  gender,longer duration of reflux symptoms.
• In scleroderma,Z-E syndrom,NG tube, Heller
  myotomy.
• Infectious esophagitis,post surgical,caustic
  injury,pill induced esophagitis,radiation
  exposure.

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Dysphagia,esophagealDifferential diagnosis

• Esophageal rings and webs
• Thin,fragile structures that partially or
  completely compromise the esophageal lumen.
• Webthin mucosal fold,covered with squamous
  epithelium,in anterior cervical esophagus,
  causing focal narrowing in the postcricoid area.

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Dysphagia,esophagealDifferential diagnosis

• Esophageal rings and webs
• RingsSchatzki ,mucosal structures at the GE
  junction , smooth,thin,(lt4mm).covered with
  squamous mucosa above and columnar epithelium
  below.
• Pathogenesis,mucosal,muscular,GERD
• Changing the caliber during peristaltism.

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Dysphagia,esophagealDifferential diagnosis

• Esophageal rings and webs
• DiagnosisBarim swallow,EGD
• Symptomsacute(steak house syndrome)
  ,intermittent,with chest discomfort
• Plummer-vinson or paterson-kelly syndrom

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Dysphagia,esophagealDifferential diagnosis

• Carcinoma
• Esophagus,gastric cardia
• History,others symptoms,age
• Histologic type
• Risk factors
• incidence

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Dysphagia,esophagealDifferential diagnosis

• Cardiovascular abnormalities
• Compressing the esophagus
• Complete vascular ring double aortic arch, R.
  aortic arch with retroesophageal
  L. subclavian artery and L. ligamentum
  arteriosum,R. aortic arch with mirror-imaging
  branching and L. ligamentum arteriosum
• Incompleteretroesophageal R.aberrent subclavian
  artery and L.pul artery

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Dysphagia,esophagealDifferential diagnosis

• Cardiovascular
• Severe atherosclerosis in elderly
• Large aneurysm of the thorasic aorta
• Enlargement of the left atrium

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Dysphagia,esophagealDifferential diagnosis

• Radiation injury
• Acute esophagitis
• Chronicgt2 months after radiotherapy
  (ulceration or strictures)
• Location
• Motility disorder

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Dysphagia,esophagealDifferential diagnosis

• Achalasia
• Etiology
• Symptoms
• Manometric abnormalities
• Secondary achalasia

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High-resolution esophageal pressure topography
,conventional manometry normal swallow
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Classic achalasia
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Achalasia with compression
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Spastic achalasia
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• Secondry achalasia

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Dysphagia,esophagealDifferential diagnosis

• Spastic motility disorders
• DES,nutcracker esophagus,hypertensive LES ,non
  specific spastic esophageal motility disorders
• Pathophysiology
• Symptoms
• diagnosis

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Variants of esophageal spasm spastic nutcracker
(left) and diffuse esophageal spasm (right)
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Dysphagia,esophagealDifferential diagnosis

• Connective tissue disorders
• Sclerodermaesophageal involvement in up to 90
  of patients
• sjogrens syndromdysphagia up to 74

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• sclroderma

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Dysphagia,esophagealDifferential diagnosis

• Functional dysphagia
• Is a diagnosis of exclusion
• Complete diagnostic evaluation is needed.
• No structural abnormality or motility
  disturbance,no reflux.
• At least 12 weeks in the preceding 12 months of a
  sense of having solid and/or liquid food
  sticking,lodging,or passing abnormally through
  the esophagus.

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Dysphagia,esophageal

• Specific testing
• Should be based upon the medical history
• Early referral for EGD
• Barium swallow in proximal esophageal lesion
• Esophageal motility study

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Acute dysphagia

• Require immediate evaluation and intervention
• Annual incidence13/100,000
• M/F1.7/1-increase with age.
• Commonly have an underlying component of
  mechanical obstraction
• Food impaction is the most common cause in adults.

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Dysphagia,oropharyngealphysiology of swallowing

• Normal swallowing consist of 3 phases (oral
  preparatory , pharyngeal , esophageal)
• Up to 600 times/day
• Once begin , it takes less than 1 second for a
  bolus to reach the esophagus,and an additional
  10-15 seconds to complete the swallow
• Involve more than 30 muscles

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Sagittal and diagrammatic views of the
musculature (involved in enacting oropharyngeal
swallowing)
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Dysphagia,oropharyngealphysiology of swallowing

• Oral preparatory phase
• The bolus is processed by mastication to an
  appropriate size,shape and consistency
• The tongue is a critical part for controlling the
  food so that proper chewing can occur and for
  directing the bolus to its proper position for
  swallowing.
• Voluntary control/cranial nerve V,VII,XII.

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Dysphagia,oropharyngealphysiology of swallowing

• Pharyngeal phase
• The bolus is advanced through the pharynx and
  into the esophagus by pharyngeal peristalsis
• Is controlled reflexively
• Cranial nerve V,X,XI,XII
• Respiration is inhibited centrally.

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Dysphagia,oropharyngealphysiology of swallowing

• Esophageal phase
• In this phase , peristaltic contractions in
  the body of the esophagus combined with
  simultaneous relaxation of the LES propel the
  bolus into the stomach

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Dysphagia,oropharyngealpathogenesis

• Disturbance in oral preparatory or pharyngeal
  phase
• Arise from diseases of the upper esophagus ,
  pharynx ,UES dysfunction

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Dysphagia,oropharyngealpathogenesis

• Disorders of the oral preparatory phase
• Poor dentition
• Decrease in salivary flow
• Neurologic disorders such as stroke, parkinsons
  dis(weakness of muscles, decrease in
  coordination)
• Disruption of the oropharyngeal mucosa

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Dysphagia,oropharyngealpathogenesis

• Disorders of the pharyngeal phase
• a normal phase requires neuromuscular
  coordination for propulsion of the bolus, an
  unobstructed lumen , and normal relaxation of the
  UES.
• Neuromuscular discoordination(CNS disorders
  egstroke,motor neuron dis eg ALS,peripheral
  neuron dis egmyastenia

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Dysphagia,oropharyngealpathogenesis

• Continue..
• Obstructions within the oropharynx malignancies
  (the most common), cervical rings or webs,
  cervical osteophytes
• Poor compliance of the UES (parkinsons dis)

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Dysphagia,oropharyngealhistory

• Specific clues in the history can help establish
  the cause of the dysphagia
• Older patients,particularly those with a history
  of alcohol abuse,smoking or weight loss
  malignant cause must be R/O
• Repositioning during the swallowingdifficulte in
  transfer of bolus
• History of dry mouth or eye

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Dysphagia,oropharyngealhistory and physical exam

• Continue
• Changes in speech(neuromuscular dysfunction,vocal
  cord paralysis,)
• Food regurgitation,halitosis,a sensation of
  fullness in the neck,or a history of pneumonia
  Zenkers diverticulum
• Pain upon swallowing inflammation,infection,malig
  nancy

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Dysphagia,oropharyngealclinical manifestations

• Pointing toward the cervical region
• Symptoms occur almost immediately after
  swallowing
• Feelig of an obstruction in the neck,
  coughing,chocking,drooling and regurgitation
• Differentiation with globus sensation,dysphagia
  related to distal esophageal dis,such as peptic
  stricture.

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Dysphagia,oropharyngealphysical examination

• Oral cavity,head and neck,supraclavicular region
  must be examed carefully
• Neurologic examination should include testing of
  all cranial nerves,especially those involved in
  swallowing (sensory components of V, IX, X, and
  motor components of V, VII, X, XI, XII).

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Dysphagia,oropharyngealdiagnostic testing

• Barium radiography
• Videofluroscopy
• Upper endoscopy
• Fiberoptic nasopharyngeal laryngoscopy
• Esophageal manometry
• The choice of specific testing depends upon
  the clinical presentation and available expertise.

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Dysphagia,oropharyngealtherapy

• The goals of treatment are to improve food
  transfer and to prevent aspiration.
• The approach chosen depends in part upon the
  cause of dysphagia
• Neoplasms resection , chemotherapy or radiation
  therapy

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Dysphagia,oropharyngealtherapy

• Following stroke , head or neck trauma, surgery ,
  or in degenerative neurologic diseases
  rehabilitation is recommended
• Therapeutic endoscopy for esophageal webs or
  strictures
• Surgical myotomy
• Botulinium toxin injection (alternative to
  cricopharyngeal myotomy)

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