Treatment and management of Dysphagia 1. Congenital abnormalities e.g congenital atresia of oesophagus and trachea_oesophageal fistula are associated.

Mostly its the lower segment that communicates with the trachea. Newborn suffers from attacks of coughing and cyanosis on feeding. Treatment Includes corrective surgery straight after diagnosis. If the distance between the two ends is long then there is no need for surgery. Instead its usual to wait for several weeks so that the two ends of the oesophagus can grow towards each otherreducing the distance. During this period the child is fed through a gastrostomy tube. Operation Thoracotomy is performed where the lower segment is divided at its entrance into the trachea and the fistula closed. 2. Foreign bodies arrested in the oesophagus Are mostly removed by endoscopy i.e flexible endoscopy is the method of choice and most of the objects can be extracted with grasping forceps, a snare or a basket. If the object is seems to injure on withdrawal an overtube should be used. N/B button batteries are a particular worry since they are difficult to grasp and its tempting to push them into the stomach. 3. Paraoesophageall (rolling) hiatus hernia Is a hernia in which the cardia remains in its normal anatomical position as majority of rolling hernias usually result in the cardia getting displaced into the chest.Most common sypmtoms of rolling hernias are mostly due to twisting and distortion of the oesophagus and stomach. Dysphagia is common. It always recquires surgical repair as its potentially dangerous! Patients who present as an emergency with acute chest pain may be initially treated by nasogastric tube to relieve the distention that caused thepain followed by repair. If pain is not relieved or perforation is suspected immediate operation is mandatory. 4. Carcinoma of oesophagus Whereby dysphagia is the usual presenting feature and is generally a sign of advanced disease. Here a gastrosomy should never be carried out! It is important to provide relief of dysphagia, as the patient should not be submitted to needlessly aggressive treatment. Surgery.curative surgery involves resection of an appropriate length of the oesophagus. The access to the oesophagus through the right chest is the best approach. The azygos vein is divided allowing easy acess to the whole intrathoracic oesophagus. A thoracotomy with entry above the 5th rib gives best access to mid-mediastinum and the thoraicic inlet. The oesophagus is divided just below the thoracic inlet giving adequate clearance since most lesion are in the middle third or lower third. The oesophagus is opened to check if the lesion is circumscribed or diffusely infiltrating.

Radiotherapyproduces long-term survival in oesophageal cancer though at present surgical resection produces the best survival rates and quality of life. The survival figures show that neither surgery not radiotherapy are particularly effective treatments. Chemotherapy.never cures, but shrinks the disease in upto60% of the cases. Intubation..with various types of expanding metal stents which produce a better lumen for swallowing though they are quite expensive. Endoscopic laser treatment may be used to core a channel through the tumour causing an improvement in swallowing. Though it does have a disadvantage of being repeated every few weeks. 5. Achalasia The two main methods of treatment are forceful dilatation of cardia and hellers myotomy. Forceful dilatationinvolves stretching the cardia with a balloon (plastic type with a fixed external diameter) to disrupt the muscle and render it less competent. Perforation is a complication, where the risk increases with bigger balloons. curative in about 75-85%cases. Results are best in people aged more than 45yrs. Hellers myotomyinvolves cutting the muscle of the lower oesophagus and cardia. The major complication is gastro-oesophageal reflux. Successful in more than 90% cases and maybe used after failed myotomy. 6. other non-neoplastic conditions Oesophagitis due to candida albicans may present with dysphagia, in patients taking steroids. Endoscopy shows numerous white plaques that cannot be moved. Treatment is with nystatin lozenges or other anti-fungal agents. Schatzkis ring Is a circular ring I the distal oesophagus. The core of the ring consists of variable amounts of fibrous tissue and cellular infiltrate. Some are associated with dysphagia and a single dilatation is curative.