Dysphagia

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Case Report
Chief Complaint(s)
27-years-old Saudi gentleman presented with progressively increasing difficulty in swallowing over one-month period.

Clinical History

Dysphagia started with solid food. However, in a matter of only four weeks, he could not even swallow liquids without difficulty. Limitation of his food intake resulted in weight loss. no previous swallowing problem. he denied having any chest pain, heartburn, regurgitation, nausea or vomiting, and there was no history of ingestion of any corrosive substance. he was not on any medications.

Clinical Physical Examination

Physical examination revealed a well developed, but thin man His vital signs were stable. There was no jaundice, no signs to suggest nutritional deficiencies. Examination of heart, lungs and abdomen were unremarkable. Liver was not enlarged and there was no ascites.

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Esophagus

BRIEF ANATOMY :

Esophagus is a tubular structure about 10 inches continuous above with laryngeopharynx opposite 6th cervical vertebra passes through diaphragm at the level of 10th thoracic vertebra where it joins the stomach in the abdomen

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BLOOD SUPPLY OF ESOPHAGUS:

Inferior thyroid artery Descending thoracic aorta

Left gastric artery

upper 3rd middle 3rd lower 3rd

Inferior thyroid vein azygos vein left gastric vein

 AREAS OF NARROWING IN ESOPHAGUS:

The aortic arch The left main bronchus The diaphragm

Normal swallowing is initiated with voluntary pharyngeal contractions pushed the food into hypopharnex where the upper esophageal sphincter relaxes. This permits an involuntary wave of contraction to progress down the normally relaxed esophagus until it reach the lower esophageal sphincter . The LES relaxes at the juncture and the contraction wave pushed the bolus into the stomach . In resting both UES and LES are contracted to prevent reflux .

DYSPHAGIA

DEFINITION OF DYSPHAGIA: Medical term means any difficulty in swallowing regardless of the cause
GRADES OF DYSPHAGIA:
mild dysphagia: only solid things can't be swallowed moderate dysphagia: solid & semi solid thing can't be swallowed severe dysphagia: even liquids can't pass

COMMON CAUSES OF DYSPHAGIA:

I. II.

CONGENITAL ACQUIRED

I.

CONGENITAL:
e.g: esophageal atresia

Acquired
^ In the lumen Foreign body Food bolus ^ In the wall Achalasia ^ Outside the wall Pressure of the enlarged lymph nodes Thoracic aortic aneurysm Bronchial carcinoma Retrosternal goitre ^ Neuromuscular disorders Myesthenia gravis Bulbar palsy Bulbar poiliomylitis

Tumour of the esophagus GERD

Plummer Vinson syndrome Pharyngeal pouch Scleroderma Chagas disease

Associated symptoms:

Difficulty in chewing or bolus preparation Excessive drooling Chocking or regurgitation Food sticking Aspiration pneumonia Weight loss Compromised nutritional status Or any combination of these

Symptoms aggravated by :

Achalasia of the Cardia

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Achalasia of the cardia

Definition Primary esophageal motility disorder characterized by:

1) Absence of peristalsis, 2) Elevated pressure of the LES, 3) Failure of the LES to relax during swallowing,
Causing functional obstruction at the gastroesophageal junction.

Clinical picture of Achalasia

History

Dysphagia (most common) Regurgitation Chest pain Heartburn Weight loss

Details

25-50% report episodes of retrosternal chest pain. 80-90% experience spontaneous regurgitation. some patients may present with signs or symptoms of pneumonia or pneumonitis. Patients with achalasia are at increased risk for esophageal cancer

Physical:
Physical examination is noncontributory.

Workup
Lab Studies

Laboratory studies are noncontributory.

Imaging Studies

UGI: Birds Beak. EGD: Normal or dilated esophagus. Manometry

The radiologic examination of choice in the diagnosis of achalasia is a barium swallow study performed under fluoroscopic guidance. Diagnosis of achalasia supported by the results of radiologic studies must always be confirmed by 1) performing (EGD) to rule out cancer of the gastroesophageal junction or fundus, and 2) esophageal manometry.

Birds Birds beak xray Beak

Normal Barium Swallow

patient?

The goal of therapy for achalasia is to relieve symptoms by eliminating the outflow resistance caused by the hypertensive and nonrelaxing LES.

1)

2)

Medical Management Surgical Management

Medical Management
a)

Botulinum toxin: intrasphincteric injection Only 30% of patient's treated endoscopically still have relief of dysphagia 1 year after treatment.

+ve elderly patients

(50% re-treat in 9 months vs 10% balloon)

-ve inflammatory reaction

b) Pharmacologic therapy: relax the smooth muscle of the LES. Calcium channel blockers - Nifedipine and verapamil Anticholinergic agents - Cimetropium bromide Nitrates - Isosorbide dinitrate Opioids - Loperamide

Approximately 10% of patients benefit

+ve

primarily in elderly patients who have contraindications to either pneumatic dilatation or surgery or as a temporary measure while other treatments are considered. -ve

These agents all have demonstrated effectiveness in decreasing LES pressure however, they frequently fail to relieve symptoms, or they are associated with significant adverse effects.

Surgical Management
a)

Pneumatic dilatation:

^ Pneumatic dilatation by a qualified gastroenterologist is the recommended treatment. ^ Dilation of LES with a bougie ( flexible cylindrical instrument ) ^ Most commonly performed by using pneumatic balloons. ^ The success rate is 70-80%, and the perforation rate is approximately 5%. ^ Approximately one half of patients experience recurrent symptoms within 5 years. ^ If a perforation occurs, emergency surgery is needed to close the perforation and perform a myotomy. ^ As many as 50% of patients may require more than 1 dilatation. ^ The incidence of abnormal gastroesophageal reflux after the procedure is approximately 25%.

b) Esophageal (Heller) myotomy:

Heller myotomy cardiomyotomy and dividing the muscle of the lower end of the esophagus and the upper stomach down the mucosa.
^

^ Heller myotomy is the appropriate treatment for patients in whom pneumatic dilatation fails. ^ The laparoscopic approach appears to be most appropriate. The results are as durable as those with an open approach. ^ Several series of laparoscopic esophageal myotomy with concomitant partial fundoplication have been reported.

Under general anesthesia, make a controlled division of the muscle fibers (myotomy) of the lower esophagus (5 cm) and proximal stomach (1.5 cm) followed by a partial fundoplication to prevent reflux . Patients remain hospitalized for 24-48 hours and return to regular activities in about 2 weeks. The operation relieves symptoms in 85-95% of patients, and the incidence of postoperative reflux is 10-15%. Patients in whom surgery fails may need a dilatation, a second operation, or removal of the esophagus (ie, esophagectomy).

Pre and Post OP

Esophageal Tumor

Benigh Tumors:
* LIOMYOMA * POLYP

Malignant Tumors

Benign Tumors

RARE The commonest is LIOMYOMA. Dysphagia , bleeding. Remove it .

What you see ??

Esophageal Carcinoma

Oesophageal carcinoma is becoming more common, unlike the trend observed in gastric carcinoma. Squamous carcinoma typically arises in the upper 2/3 of the oesophagus Adenocarcinoma usually arises in a region of specialised columnar epithelium (SCE) metaplasia in the lower 1/3 of the oesophagus - Barrett's oesophagus.

Clinical Features

Dysphagia is the most frequently presented feature of oesophageal carcinoma : patient may recount a short history of progressive dysphagia, initially affecting solids only, but gradually affecting the swallowing of fluids. interruption of the passage of food may cause the individual to slowly alter the diet from solid to liquid nutrition.

Clinical Features

the level at which difficulty in swallowing is encountered may be identifiable by the patient. history of dysphagia in an elderly male is almost certainly carcinoma of the oesophagus or the cardia of the stomach.

Short

Clinical Features

Other local features may include :

regurgitation of food or blood-stained vomit aspiration pneumonia pain :

classically, retrosternally and in the interscapular region it may radiate to the jaws and arms

Clinical Features

General manifestations of malignant disease may include :

Loss of Weight Anorexia Anemia Coughing Edema

Secondary deposits occur in:

lymph

nodes in the liver causing jaundice

Diagnosis

The diagnosis of oesophageal carcinoma is made on :

History and examination Barium swallow Endoscopy and biopsy Cytology CT scan Bronchoscopy Ultrasound

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Investigations

Barium swallow :

the first-line investigation after the history of dysphagia characteristic image of an irregular stricture with shouldered margins, 4-10 cm long and often tortuous a tracheo-oesophageal fistula may also be demonstrated

Investigations

Investigations

Endoscopy and Biopsy :

establishes histology and limits of lesion can be used therapeutically to dilate, so improving nutrition before a definitive operative intervention

Investigations

cytology by washing / abrasion technique - used for screening in China CT scanning helps to determine mediastinal involvement and whether metastasis has occurred to the liver bronchoscopy may be needed to exclude bronchial involvement in upper and middle-third lesions ultrasound may be used to identify secondary liver deposits

Management

Management of oesophageal carcinoma is dependent on the level of the lesion and the stage of the disease.

Upper third lesion Middle third lesion Lower third lesion

Management

Upper third lesion: high dose radiotherapy is indicated for lesions up to 5 cm long. Vital structures in the mediastinum closely related to the upper third make surgical clearance and resection very difficult. Middle third lesion : Early tumours are resectable. Again, radical radiotherapy may be indicated if the lesion is up to 5 cm long . Lower third lesion : most accessible surgically; adenocarcinomas are radioresistant

Management

Extensive disease requires palliation of dysphagia:

endoscopic laser surgery for lesions less than 8 cm long oesophageal stenting e.g. with a Celestin tube - if longer than 8 cm alternatives include:

oesophago-gastrostomy or oesophago-jejunostomy short course radiotherapy

(GERD) Gastroesophageal reflux disease

Episodes of gastroesophageal reflux occurs normally in asymptomatic individuals However excessive duration and frequency of reflux events lead to symptomatic illness referred to as

BUT The clinical features of GERD occur only when the anti-reflux mechanisms fail.

(GERD)

PATHOGENESIS

LOS tone is reduced

Frequent Transient LOS relaxations

increased mucosal sensitivity to gastric acid & reduced esophageal clearance of acid

The LOS tone fails to increase when intra-abdominal pressure is increase.

PATHOGENESIS
Poor oesophageal peristalsis. Hiatus hernia can impair the pinchcock mechanism of crural diaphragm. Delayed gastric emptying. Prolonged episodes of gastrooesophageal reflux which occur at night & postprandially.

Factors associated with increased Gasrtoesophageal reflux:-

CLINICAL FEATURES

Symptoms:

Heart burn Acid regurgitation Dysphagia Extraesophageal symptoms:Asthma Recurrent pneumonia Chronic cough Angina like chest pain Laryngitis (horseness)

Signs:

Usually absent

Complications
I.
II. III.

Peptic stricture Barrett's esophagus Adenocarcinoma

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INVESTIGATION

Specific investigations:CBC to rule out anaemia due to blood loss.

Endoscopy with biopsy:

best way to diagnosis mucosal injuries, hiatal hernia, peptic stricture & Barrett's oesophagus & may be used to dilate peptic strictue

INVESTIGATION

Esophageal Manometry: Used to assess LOS pressure & peristalsis

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INVESTIGATION

Esophageal PH monitoring:

To measure esophageal PH as to differentiate between physiological and pathological esophageal acid exposure. Usually when the PH < 4 its pathological

INVESTIGATION

BARIUM SWALLOW:To identify Hiatal Hernia & Strictures

Management of GRED

Aims of therapy:
1. 2. 3. 4.

Relive symptoms. Heal esophageal mucosa. Prevent & manage complications. Maintain remission.

Treatment of GRED is a stepwise approach starting with:

1. 2. 3.

General measures. Drugs. Surgery.

Pharmacological therapy
Group H2blockers e.g ranitidine PPI e.g omeprazole Prokinitic e.g cisapride

Action

. Decrease

\\ \\

acid reflux \\ \\

Increase LES tone Increase esoph. Peristalsis Increase gastroesoph. Motility .

Surgical management

1. 2. 3. 4.

5.

Indication : Unresponsiveness to medical Rx Apnoeic spells Repeated attack of asipration Persistent reflux & stricture of esophagus after ttt of TEF MR or brain damage .

operations

Fudoplication;

A- Nissen----- fundus of stomach is wrapped complete around lower esophagus B- belsey ----- thoracic procedure in which esoph. Is sutured to diaphragm & to fundus of the stomach C- hill ---- cardia is tightend & fixed to peraortic fascia . This is mainly in adult , b\c children keep growing

Antireflux procedure
Angelchick prosthesis : - prosthetic collar around the lower oesophagus. Also mainly in adult.

Gastrostomy - used as an aid in the nutritional support of pt w/ CNS dysfunction.

Complication
Recurrence Gas bloat syndrome ---- as result of stomach fills w/ air & pt feels very full after meals & passes excessive flatus. Dislocation of the wrapped fundus .

MCQs

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Q1) In Achlasia cardia all are present except :

a) Aperistaltic esophagus b) Failure of LES relaxation c) Elevated LES pressure d) Increased esophageal pressure i.e. more than gastric pressure

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Q2. All investigations are done to differentiate non cardiac chest pain from cardiacchest pain except?
a)24 hr ph monitoring b)Bernstein test c)Manometry d)Balloon distension

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Q3. Which of the following statements about achalasia is/are correct?

A. Chest pain and regurgitation are the usual symptoms. B. Distal-third esophageal adenocarcinomas may occur in as many as 20% of patients within 10 years of diagnosis. C. Manometry demonstrates failure of LES relaxation on swallowing and absent or weak simultaneous contractions in the esophageal body after swallowing. D. Endoscopic botulinum toxin injection of the LES, pneumatic dilatation, and esophagomyotomy provide highly effective curative therapy for achalasia.

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Q4. When assessing gastroesophageal reflux disease by manometry each of the following statements is correct except one. Identify the incorrect one.

A. Absent or extremely low LES pressures have predictive value in identifying more severe reflux. B. Peristaltic dysfunction increases with increasing severity of esophagitis. C. With established reflux disease the UES is hypertensive. D. Esophageal functional changes are worst in patients with a circumferential columnar-lined esophagus. E. Absence of peristalsis may be associated with more severe forms of reflux disease

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