APPROACH TO DYSPHAGIA

BY MAHIRAH AND DIANA

 Definition
Difficulty in eating as a result of disruption in the swallowing process. Can
be divided into oropharyngeal and oesophageal dysphagia
 Causes of dysphagia
In each anatomic region, the dysphagia can be caused by neuromuscular
dysfunction ( impaired physiology of swallowing) or mechanical
obstruction to the lumen
Oropharyngeal dysphagia
Neuromuscular disorder
• Stroke
• Parkinson’s disease
• Brain stem tumours
• Degenerative conditions (amyotrophic lateral sclerosis, multiple sclerosis)
• Peripheral neuropathy
• Myasthaenia gravis
• Myopathies e.g myotonic dystrophy

Obstructive lesions
• Tumours
• Abscess
• Oesophageal webs
• Pharyngeal pouch
• Anterior mediastinal mass
 Oesophageal dysphagia

Neuromuscular disease
• Achalasia
• Spastic motor disorders
▪ Diffuse oesophageal spasm
▪ Hypertensive lower oesophageal sphincter
▪ Nutcracker oesophagus
• scleroderma

Obstructive lesions
• Intrinsic structural lesions
❖ Tumours
❖ Stricture – reflux oesophagitis, radiation, chemical, medication
❖ Lower oesophageal rings
❖ Oesophageal webs
❖ Foreign bodies
• Extrinsic structural lesions
❖ Vascular compression (enlarged aorta or left atrium)
❖ Mediastinal masses – retrosternal thyroid, lymphadenopathy
Others
• Oesophagitis – reflux, infections (candida, herpes), radiation-induced, medication-induced, chemical-induced
(alcohol)
 Reference
• Medscape - https://emedicine.medscape.com/article/2212409-
overview
• Surgery notes for the MBBS
Pathophysiology of
dysphagia
• Impaired physiology of swallowing
• 3 phase : oral phase, pharyngeal phase, oesophageal phase
• Mechanical dysphagia – caused by a large bolus or a narrow lumen
• motor dysphagia – due to weakness of peristaltic contraction or to
impaired deglutitive inhibition causing non peristaltic contractions
and impaired sphincter relaxation
Oropharyngeal phase
• The oropharyngeal stage of
deglutition begins with contractions
of the tongue and striated muscles of
mastication. The muscles work in a
coordinated fashion to mix the food
bolus with saliva and propel it from
the anterior oral cavity into the
oropharynyx, where the involuntary
swallowing reflex is triggered6
(Figure 1a). The cerebellum controls
output for the motor nuclei of cranial
nerves V, VII and XII. The entire
sequence lasts about one second.
The tongue initially forms the food bolus (green) with
compression against the hard palate.
 Oropharyngeal phase
Displacement of the food
bolus into the pharynx by
• In the posterior oropharynx, a complex and the tongue initiates
precisely coordinated succession of muscular deglutition.
contractions and relaxations occurs. The soft
palate elevates to close the nasopharynx, and
the suprahyoid muscles pull the larynx up and
forward6 (Figure 1b).
• The epiglottis moves downward to cover the
airway while striated pharyngeal muscles Relaxation of the
contract to move the food bolus past the cricopharyngeal muscle
cricopharyngeus muscle (the physiologic (the physiological upper
upper esophageal sphincter and into the esophageal sphincter)
proximal esophagus6 (Figure 1c). This permits movement of
swallowing reflex lasts approximately one the food bolus into the
second and involves the motor and sensory proximal esophagus.
tracts from cranial nerves IX and X.
Oral phase

• Associated with poor bolus formation and control

• Food may either drool out of the mouth or overstay in the mouth
• Patient may experience difficulty in initiating the swallowing reflex
• Premature spillage of food into the pharynx and aspiration into the
unguarded larynx and/or nasal cavity
• Logemann's Manual for the Videofluorographic Study of
Swallowing cites the following oral-phase swallowing symptoms and
disorders:
• Inability to hold food in the mouth anteriorly due to reduced lip
closure
• Inability to form a bolus or residue on the floor of the mouth due to
reduced range of tongue motion or coordination
• Inability to hold a bolus due to reduced tongue shaping and
coordination
• Inability to align teeth due to reduced mandibular movement
• Logemann's Manual for the Videofluorographic Study of
Swallowing cites the following oral-phase swallowing symptoms and
disorders:
• Delayed pharyngeal swallow
• Nasal penetration during swallow due to reduced velopharyngeal
closure
• Laryngeal penetration and aspiration due to reduced closure of the
airway entrance (arytenoid to base of epiglottis)
• Delayed pharyngeal transit time
 Oesophageal phase
• As food is propelled from the pharynx into the esophagus, involuntary contractions of the skeletal

muscles of the upper esophagus force the bolus through the mid and distal esophagus. The medulla

controls this involuntary swallowing reflex, although voluntary swallowing may be initiated by the

cerebral cortex. The lower esophageal sphincter relaxes at the initiation of the swallow, and this

relaxation persists until the food bolus is propelled into the stomach. It may take eight to 20 seconds

for the contractions to drive the bolus into the stomach

Oesophageal-phase disorders
• Impaired esophageal function can result in retention of food and liquid in
the esophagus after swallowing.
• This retention may result from a mechanical obstruction, a motility
disorder, or an impairment of the opening of the lower esophageal
sphincter.

• Logemann's Manual for the Videofluorographic Study of Swallowing cites the

following oral-phase swallowing symptoms and disorders:
✓Esophageal-to-pharyngeal backflow due to esophageal abnormality
✓Tracheoesophageal fistula
✓Zenker diverticulum
✓Reflux
References
• https://emedicine.medscape.com/article/2212409-overview#a5

• Pathophysio according to diseases

• https://www.mayoclinic.org/diseases-conditions/dysphagia/symptoms-
causes/syc-20372028
HISTORY TAKING PATIENT
WITH DYSPHAGIA
 1. Is there odynophagia (pain associated with
difficulty swallowing)?
• Signifies some form of oesophagitis: infectious (candida, herpes), post-
radiation, chemical-induced (usually alcohol), reflux oesophagitis

• Oesophageal spasm

• Scleroderma

• Pain occurs late in achalasia and oesophageal cancer (not painful from the
start)
2. Differentiating oropharyngeal from oesophageal
dypshagia
(i) Oropharyngeal (ii) Oesophageal

Presenting complaint is usually of difficulty in Presenting complaint is that of food “getting stuck”
initiating swallowing in the throat or chest

-May be associated with choking, coughing, nasal Patient‘s localisation of the symptom often does not
regurgitation correspond to actual site of pathology
-Voice may sound nasal (bulbar palsy)

Cause of oropharyngeal dysphagia is usually Can be due to either neuromuscular dysfunction or

neuromuscular rather than mechanical; stroke is the mechanical obstruction
most common cause
 3. Differentiating mechanical obstruction from
neuromuscular dysfunction
(i) Mechanical (ii) Neuromuscular

Patient complains of more difficulty swallowing solids Patient complains of more difficulty swallowing
than fluids fluids than solids

Recent onset dysphagia that is progressively Dysphagia more long-standing, slowly progressive
worsening, with loss of weight - high suspicion of
oesophageal cancer

Intermittent symptoms are suggestive of webs, rings Intermittent symptoms suggestive of diffuse
oesophageal spasm, nutcracker oesophagus

May have regurgitation of undigested food May have history of stroke, neuromuscular disease
 4. History of predisposing conditions
• Reflux symptoms e.g. retrosternal burning pain (heartburn), sour fluid reflux into mouth
(acid brash), excessive salivation (water brash), postural aggravation on lying down

• Caustic chemical ingestion in the past

• Smoking, chronic alcohol intake

• Radiation to the chest

• Medication history

• Symptoms of systemic disease e.g. stroke (focal neurological deficits), scleroderma

(telangiectasia, sclerodactyly, calcinosis, Raynaud‘s), Parkinson‘s
 4. History of predisposing conditions
Medications associated with dysphagia
Medications that can cause direct esophageal mucosal injury
Antibiotics
Doxycycline (Vibramycin)
Tetracycline
Clindamycin (Cleocin)
Trimethoprim-sulfamethoxazole (Bactrim, Septra)
Nonsteroidal anti-inflammatory drugs
Alendronate (Fosamax)
Zidovudine (Retrovir)
Ascorbic acid
Potassium chloride tablets (Slow-K)*
Theophylline
Quinidine gluconate
Ferrous sulfate
 4. History of predisposing conditions
Medications associated with dysphagia

Medications, hormones and foods associated with reduced lower esophageal sphincter tone and
reflux11
Butylscopolamine
Theophylline
Nitrates
Calcium antagonists
Alcohol, fat, chocolate
 4. History of predisposing conditions
Medications associated with dysphagia
Medications associated with xerostomia11
Anticholinergics: atropine, scopolamine (Transderm Scop)
Alpha adrenergic blockers
Angiotensin-converting enzyme inhibitors
Angiotensin II receptor blockers
Antiarrhythmics
Disopyramide (Norpace)
Mexiletine (Mexitil)
Ipratropium bromide (Atrovent)
Antihistamines
Diuretics
Opiates
Antipsychotics
 5. Systemic review
• Loss of weight occurs in cancer and achalasia, but of much later onset in
achalasia compared to cancer

• Symptoms of anaemia (bleeding from tumour, or as part of Plummer-Vinson

syndrome)

• Symptoms of aspiration pneumonia – fever, cough, shortness of breath

 6. Tumour spread

• Hoarseness (recurrent laryngeal nerve)

• Fever, cough and haemoptysis (tracheo-oesophageal fistula)

• Haematemesis (invasion into aorta)

• Neck lump (lymph node)

PHYSICAL EXAMINATION OF
PATIENT COME WITH DYSPHAGIA
 1. General condition
• Vitals: the patient may be hypovolaemic from vomiting/decreased intake

• Nutrition: presence of cachexia

• Conjunctival pallor: bleeding from tumour, oesophagitis ulcerations, or

associated with Plummer-Vinson syndrome (PVS)

• Scleral icterus: metastases to liver

• Dehydration (mucous membranes, skin turgor, etc)

 2. Disease
• Presence of cervical lymph nodes (esp Virchow‘s node)
• Scars/marks over the chest and abdomen suggesting previous surgery,
radiation
• Palpable mass in abdomen (not likely)
• Hepatomegaly
• Ascites
• PR examination for malaena
 3. Complications of disease

• Signs of pneumonia: patient febrile, may be toxic, lung crepitations,

decreased, air entry usually over right lower lobe
 4. Treatment
• Tube feeding through NG tube, gastrostomy/jejunostomy – if aspirates
seen, what is the colour?
Condition Diagnoses to consider
Progressive dysphagia Neuromuscular dysphagia
Sudden dysphagia Obstructive dysphagia, esophagitis
Difficulty initiating swallow Oropharyngeal dysphagia
Food “sticks” after swallow Esophageal dysphagia
Cough
Early in swallow Neuromuscular dysphagia
Late in swallow Obstructive dysphagia
Weight loss
In the elderly Carcinoma
With regurgitation Achalasia
Progressive symptoms
Heartburn Peptic stricture, scleroderma
Intermittent symptoms Rings and webs, diffuse esophageal spasm, nutcracker esophagus
Pain with dysphagia Esophagitis
Postradiation
Infectious: herpes simplex virus,
monilia
Pill-induced
Pain made worse by:
Solid food only Obstructive dysphagia
Solids and liquids Neuromuscular dysphagias
Regurgitation of old food Zenker's diverticulum
Cerebrovascular accidents, muscular dystrophies, myasthenia
Weakness and dysphagia
gravis, multiple sclerosis
Halitosis Zenker's diverticulum
Dysphagia relieved with repeated swallows Achalasia
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Dysphagia made worse with cold foods Neuromuscular motility disorders
MAKING DIFFERENTIAL
DIAGNOSIS

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35
 DYSPHAGIA
INVESTIGATIONS

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Diagnostic
1. Barium swallow
• Advantage of barium swallow is that it is less invasive than OGDS,
especially when suspecting webs, diverticula in the oesophagus where
OGDS may cause perforation; however if patient is at high risk of
aspiration, barium swallow is dangerous.
• Visualisation of obstructive lesions:
• Shouldering of a stricture (benign strictures form a smoother
contour whereas malignant strictures form a more irregular
mucosal fold)
• Bird’s beak sign of achalasia

37
Achalasia Benign esophageal stricture (peptic stricture) Scleroderma with esophageal cancer and
peptic stricture

38
2. Oesophagogastroduodenoscopy (OGDS)
• Advantage is direct visualisation of the lesion and ability to take
tissue biopsy (especially useful in malignancy), may also be
therapeutic (stopping bleeding from a tumour, stenting the lumen,
etc)

3. Manometry
• Gold standard for diagnosing achalasia:
➢Absence of peristalsis
➢Very high pressures at the lower oesophageal sphincter
➢Absence of relaxation at the LES on swallowing food

39
4. Videofluoroscopic examination of swallowing (VFES) or
flexible-endoscopic examination of swallowing (FEES)
• Used to assess oropharyngeal dysphagia (neuromuscular causes) by
looking for penetration and aspiration of various consistencies of
food during swallowing

40
Supportive
1. Blood investigations:
• Full blood count – Low Hb (anaemia from chronic blood loss)
High TW (aspiration pneumonia)
• BUSE – electrolyte disturbances from vomiting, poor intake; raised creat and urea in dehydration
(creat will be raised more than urea if patient has prerenal failure from dehydration)
• Liver function tests – low albumin with nutritional deprivation

2. CXR
• Consolidation (aspiration pneumonia)

3. 24-hour pH probe monitoring

• If patient complains of reflux symptoms and no signs are seen on OGDS

41
Barium swallow studies
Suspected obstructive lesion (e.g., Schatzki's ring, tumor)
Suspected esophageal motility disorder
Double-contrast upper gastrointestinal evaluation
Suspected esophageal mucosal injury
Evaluation of oropharyngeal anatomy and function (fluoroscopy)
Suspected gastroesophageal reflux disease
Gastroesophageal endoscopy
Suspected acute obstructive lesion (impacted food bolus)
Evaluation of the esophageal mucosa
Confirmation of a positive barium study with biopsies or cytology
Manometry
Abnormality not identified on barium study or by endoscopy
pH monitoring
Suspected gastroesophageal reflux disease
Videoradiography
Suspected risk of aspiration 42
43
References
• Bailey & Love's Short Practice of Surgery 27th Edition .
• Surgery Notes by Andre Tan
• Radiopaedia.org, the wiki-based collaborative Radiology resource.
(n.d.). Radiopaedia. https://radiopaedia.org/

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Treatment of Dysphagia
TREATMENT
► Cause directed.
► In case of chronic progressive dysphagia patient is
first resuscitated before undergoing any surgery.
 TREATMENT
1. Tracheoesophageal fistula (Paediatric surgery): The supportive measures include
nasogastric drainage, tracheostomy, gastrostomy, and intravenous hydration and
antibiotics.
2. Pharyngeal pouch (ENT): Treatment by endoscopic stapling diverticulotomy.
3. Carcinoma of the trachea and bronchus (thoracic surgery)
4. Ca esophagus: Depends on stage. May be palliative or esophagectomy with adjuvant
therapy
5. GERD: antireflux treatment. ± surgery
TREATMENT
6. Caustic stricture: dilatation, or the conservative approach, is the primary treatment
method.
7. Foreign body: endoscopic removal.
8. Food bolus: drinking liquid, or spirit etc or endoscopic crushing of the food bolus or
removal.
9. Achalasia: graded pneumatic dilation (PD) or laparoscopic surgical myotomy with a
partial fundoplication / Botulinum toxin therapy / Pharmacologic therapy / nitrates
and calcium channel blockers.
10. Scleroderma: PPIs, antacids, elevation of the bed, multiple dilatation. Partial
fundoplication.