DYSPHAGIA

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


QuestionQuestion-2


     

A 52 year-old male executive c/o intermittent dysphagia yearwhich 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

INTRODUCTION
 Dysphagiadifficulty Dysphagia

with swallowingis a swallowing common condition, reported by 58% of the 5 general population aged over 50 years, and by 16% of the elderly.  Dysphagia, particularly oropharyngeal dysphagia, is even more common in the chronicchronic-care setting; up to 60% of nursingnursinghome occupants have feeding difficulties that include dysphagia.

ESOPHAGEAL ANATOMY

ESOPHAGEAL ANATOMY

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 2424hour period

Esophageal Anatomy
Upper one-third is composed of skeletal muscle one Distal two-thirds is smooth muscle two 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


REVIEW


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

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

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

Stage 3


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

HISTORY
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 patientspatients-80 -crucial for determining whether subsequently detected radiographic or endoscopic 'anomalies' are relevant or incidental..
 Taking

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), xerostomiaxerostomia-loose the lubrication properties and stimulus odynophagiaodynophagia-transient than dysphagia, and persists only during the 15 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.

Where is the site of bolus hold-up? holdRetrosternal bolus hold-up indicates that the disorder holdlies within the esophagus.  However, the patient's perception of an apparent bolus hold-up in the neck has low diagnostic holdspecificity, 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 holdnotch when the actual hold-up is within the holdesophageal


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

OROPHARYNGEAL VS ESOPHAGEAL

Etiology of oropharyngeal dysphagia.

                  

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

ESOPHAGEAL
 

 

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

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

 Motility

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

ESOPHAGEAL
 Differntiation

mechanical vs motility disorder?

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,

MotilityMotility- 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 refluxrefluxrelated pain.

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



Slowly progressive, long-standing dysphagia, particularly against a longbackground 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 dysphagia or months) and associated weight lossis highly suggestive of esophageal loss cancer. LongLong-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.

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

Investigation of esophageal dysphagia

 Barium

swallow study,  Endoscopy and  Esophageal manometry. manometry.

NO DYSPHAGIA

INTERMITTENT DYSPHAGIA FOR SOLIDS

DYSPHAGIA WITH LONG HX OF GERD

Bulge in the left side of the neck while eating

DYSPHAGIA FOR SOLIDS AND LIQUIDS WITH WT LOSS

DYSPHAGIA FOR SOLIDS AND LIQUIDS

young male patients who present with intermittent dysphagia or bolus impaction

INTERMITTENT DYSPHAGIA FOR SOLIDS AND LIQUIDS

nonpropulsive contractions  corkscrew/ rosary bead esophagus
 Numerous

INTERMITTENT DYSPHAGIA FOR SOLIDS

IRON DEFIIENCY ANEMIA

Due to an aberrant right subclavian artery coursing posterior to esophagus