DYSPHAGIA

Learning Outcomes
1. Definitions
2. Benign Vs Malignant Causes
3. Clinical sign and symptoms
4. How to evaluate patient with GERD/ca
5. Medical causes of dysphagia
6. GERD
7. Barrett’s Esophagus
8. Achalasia
9. Hiatus Hernia
10. Oesophageal Ca
11. Diffuse Oesophageal Spasm
Case study
Demographic data.

Name: Khairuddin Salleh

Age: 69 years old
Sex: Male
Race: Malay
Occupation: Retired restaurant owner.
Address: Sitiawan , Perak.
Chief complaint.

• En Khairuddin Salleh, 69 y/o man came to the hospital due to progressive difficulty in swallowing for
the past 10 months associated with persistent coughing and weight loss since 7 months ago.
History of presenting illness.

He had progressively difficulty in swallowing ten months ago. Recently, he was about to take his lunch
at home when suddenly he feels severe difficulty in swallowing food associated with pain at the chest.The
duration of the pain is four days ago. It is continuous and gradually worsening. The character of the pain is
sharp pain. The pain analog score is 7/10. There is no precipitating factor for the pain. The aggravating
factor for the pain is when swallowing food. There is no relieving factor for the pain. The pain is associated
with persistent coughing seven months ago.It is intermittent and does not worsen. The character of the
cough is productive with clear sputum. There is no hematemesis and the cough is not associated with
food and posture.The patient also has loss of weight seven months ago due to difficulty in swallowing
food.
Systemic review.

● CVS - No palpitation, pedal oedema.

● Respiratory - No shortness of breath.
● CNS - No loss of consciousness, seizure, headache, vomiting, motor weakness, sensory loss.
● Endocrine - No heat/cold intolerance.
● Reproduction - No urethral discharge.
● MSK - No joint pain, myalgia.
● Skin- No rashes, bruises.
● Hematology - No bleeding disorders, fatigue.
Vital signs.

BP : 121/84 mmHg
PR : 84 bpm
RR : 20 bpm
Temperature : 37 oC
SpO2 : 96% under room air.
Past medical history.

He has history of pulmonary tuberculosis which has been diagnosed 25 years ago and was treated
with anti-tuberculosis. He also has history of peptic ulcer disease with occasional regurgitation and
heartburn for 10 years. Other than that, he has no history of diabetes, hypertension or bronchial
asthma. He has no known drug allergy and no known food allergy.

Past surgical history

He never undergo any surgery.

Family history.

• Family members does not suffer the same disease as him.

• No underlying comorbidities such as diabetes mellitus, hypertension and malignancy.
Social history.

He is married and blessed with 2 children. He is a retiree restaurant owner with Middle-income family.
He is a chronic smoker for 50 years with 12 sticks per day. He does not drink alcohol. He sleep regularly.
He eats a normal diet. He has no recent travel history.
Physical examination.
General inspection.
– Ill looking
– Breathing normally
– No respiratory distress
– Cannula at his left hand
– Average body built
General examination.
– No koilonychia
– No leukonychia
– No clubbing
– Hands are moist and warm.
– No peripheral cyanosis
– Has no conjunctival pallor
– No jaundice
– Oral hydration is poor.
– Oral hygiene is good
– No angular stomatitis
Abdominal examination.

Inspection.
- Shrunken shape
- No surgical scars
- Moves with respiration
- Umbilicus centrally located and inverted
- No visible pulsation & peristalsis
Palpation.
• The abdomen is soft and non tender
• No organomegaly and no mass palpable
Percussion
• No shifting dullness
Auscultation
• Bowel sound is heard
Provisional diagnosis.

Malignancy:
1. Adenocarcinoma of Gastroesophageal Junction
Differential diagnosis.

1. Recurrence peptic ulcer disease.

2. Recurrence tuberculosis.
Management.

• Improvement of general condition

• Radiotherapy
• Chemotherapy
• Surgery.
 1. Definition of dysphagia

Dysphagia is defined as difficulty in swallowing

which may effect any part of the swallowing
pathway from the mouth to stomach.
2. Benign Vs Malignant causes
Benign tumors Malignant tumors

Classified as mucosal or intramural Types of tumors:

Mucosal: fibrovascular polyps, granular - Squamous cell carcinoma
cell tumour, papillomas and lipomas. - Adenocarcinoma
Intramural: leiomyomas and cysts - Sarcoma
- Lymphoma
- Primary melanoma
- Metastatic tumours (breast, lung, melanoma)

- Barium swallow (determine lesion is
intramural or mucosal)
- Endoscopy (determine the tumor’s
nature:
Intramural: smooth protrusion
Mucosal: may sometimes ulcerate.
It should be suspected in individual with recent dysphagia
particularly after the age of 50.
- Barium swallow
- Endoscopy
- Computed tomography (CT)
- Endoscopic ultrasound (EUS)
- Bronchoscopy

-Surgical enucleation for intramural - Tumor resection

lesion - Chemotherapy
- Polyps are treated by local resection - radiotheraphy
3. Clinical Sign and
Symptoms
 Clinical Sign and Symptoms
Acute
Chronic
Shortness of Breath
Weight loss
Change of Color
Recurrent chest infection
Spiking temperature
Dehydration
Chest infection
Hunger
Coughing during or after swallow
Lengthened mealtimes
Difficulty managing saliva
Refusal to eat or drink
Effortful chewing and swallowing
Medical Causes of
Dysphagia
Foreign Bodies

Causes obstruction

Motility disorders

Such as motility disorder and achalasia

Neurological disease

Such as myasthenia gravis,multiple sclerosis,cereberovascular disease and lead to oropharyngeal

dysmotility

Reflux oesophagitis

Oesophageal webs

Pharyngeal pouch

Oesophageal Carcinoma.
Diagnostic Investigations
Investigation

● Dysphagia should always investigated urgently

● Endoscopy is the investigation of choice because
it allows biopsy and dilatation of stricture
● If no abnormality is found, then barium swallow
with videofluoroscopic assessment is indicated to
detect major motility disorders
● High resolution manometry allows accurate
classification of abnormalities
Barium Swallow
High Resolution Manometry
A gastrointestinal motility diagnostic system that measures intraluminal pressure activity in the
gastrointestinal tract using a series of closely spaced pressure sensors.
How to Evaluate Patients with
GERD/Ca
History.
• Age:
➢ Dysphagia of a young male -- eosinophilic oesophagitis.
➢ In a patient >40 years old --commonly due to Schatzki ring.
➢ Patients older than 50 years old --concern for oesophageal cancer
➢ Symptoms : Taste of sour brush (after meal).
➢ PMH : History of warded due to GERD/Ca.
➢ Family history : Among family members with the same symptoms.
: History of malignancy
Symptoms onset.
➢ Dysphagia primarily to solid foods is probably indicative of a structural lesion,
➢ Dysphagia to both solid and liquid from the onset of symptoms is most likely to be due to
motility or neurological disorders of the pharynx or oesophagus.
➢ Duration and progression of symptoms:
➢ Rapid progression of dysphagia + weight loss --suggestive for malignancy
➢ Long-standing history of dysphagia --peptic strictures.
➢ Intermittent solid food dysphagia-- esophageal rings
➢ Progressive dysphagia -stricture and cancer cause.
➢ Heartburn and regurgitation (after meals).
Associated symptoms.

➢ Difficulty initiating a swallow along with coughing, choking, hoarseness, gagging, and
nasal regurgitation is more suggestive of--- oropharyngeal dysphagia.
➢ Chest pain is often seen in-- idiopathic achalasia and diffuse esophageal spasm.
➢ Previous history of heartburn is suggestive of-- peptic stricture.
Physical examination.
• Patient's level of alertness and cognitive status, including vital signs
• Complete head and neck examination
– Inspection of oral cavity
– Dentition
– Oropharynx
– Cranial nerve examination ( tongue, gag and cough reflex, hoarseness, vocal cord mobility)
– Neck for lymph nodes, neck masses, thyroid enlargement, loss of laryngeal crepitus and
integrity of laryngeal cartilages
● Abdominal examination - tenderness at the epigastric area indicates heartburn/GERD.
GERD
Definition
- Symptoms or mucosal damage produced by the abnormal reflux of
gastric contents into the esophagus.

Prevalence
- Prevalence of GERD in hospital settings ranges from 12.4% - 31.7% in
asian countries (H.K Jung, 2011)
- Prevalence of GERD in Southeast and Western Asia is higher in
comparison to Western Asia.
Clinical manifestation
Typical symptoms are acid regurgitation and heartburn.

- Regurgitation is the perception of flow of refluxed gastric contents into

the mouth or hypopharynx
- Heartburn is defined as a burning sensation in the retrosternal region.

Other presenting symptoms include, nausea, chest pain, epigastric pain,

belching, early satiety, bloating.
- Non-cardiac chest pain (NCCP) is common among Asian patients and may
be a presenting feature of GERD
Diagnosis and evaluation
- History - clinical diagnosis
- PPI diagnostic test
- Endoscopy with biopsy
- Ambulatory pH probe test

Treatment
- PPI - pantoprazole, omeprazole
- H2 receptor antagonist - cimetidine, ranitidine
- Antacids and alginates
Barrett’s oesophagus
Definition

● Abnormal changes (metaplasia) in the cells of the lower portion of the

esophagus.
● Characteristic: replacement of the normal stratified squamous epithelium
lining of the esophagus by simple columnar epithelium with goblet cells
(which are usually found lower in the gastrointestinal tract)
Prevalence

● Found in 5 – 15 % of patients who have GERD

● Risk of developing adenocarcinoma in Barrett esophagus is approximately 50 – 100
times that of general population
Symptoms

● Arise from chronic GERD :

1. Heartburn
2. Dysphagia
3. Bleeding ( about 25%)
4. Regurgitation
Diagnosis

1. Endoscope
2. Biopsy

* Barrett’s epithelium is the presence of mucus-secreting goblet cells (intestinal

metaplasia)
Complications
1. Esophageal ulcerations and stricture
- the stricture is located at the squamocolumnar junction which may be found proximal to GE junction.

2. Adenocarcinoma

- adenocarcinomas above the GE junction are characteristics of malignant degeneration in Barrett

esophagus.

- rare event in Barrett esophagus patients.

3. Dysplasia

- malignant degeneration from benign to dysplastic to malignant epithelium occurs in Barrett esophagus.
Treatments
1. For asymptomatic uncomplicated Barrett esophagus patients, do endoscopic
surveillance and biopsy annually.
2. For symptomatic uncomplicated Barrett esophagus patients, treat like GERD patients
+ periodic endoscopic surveillance with four-quadrant biopsy (biopsy from 4 quadrants
at standard intervals within the esophagus or purely at random)
3. Barrett ulcers – 8 weeks of treatment with PPI
4. Strictures – periodic esophageal dilation
5. Dysplasia :
(i) low grade dysplasia – every 3 to 6 months surveillance esophagoscopy & biopsy
* GERD treatment is recommended even asymptomatic.
(ii) high grade dysplasia
– indication for esophagectomy
– non-resective method (eg : endoscopic musocal resection & radiofrequency ablation)
6. Adenocarcinoma – indication for esophagogastrectomy
 Disease D: Hiatus hernia

A hernia is when part of the body bulges or protrudes into

another part of the body that would not normally contain it.
In the case of a hiatus hernia, a part of the stomach,
normally in the abdomen, slides or protrudes into the chest
cavity
Types:
Sliding hiatus hernia: this is the most
common type of hiatus hernia, accounting
for about 90 per cent of cases. It occurs
when the junction between the oesophagus
and the upper part of the stomach protrude
up through the oesophageal opening in the
diaphragm into the chest cavity. The
herniated portion of the stomach can slide
back and forth, into and out of the chest.
Rolling hiatus hernia: this is sometimes
called a para-oesophageal hiatus hernia. In
this case, the junction of the oesophagus
and stomach stays down within the
abdomen, and the top part of the stomach
(the fundus) bulges up into the chest cavity.
This type of hernia normally remains in one
place, sitting next to the oesophagus, and
does not move in or out when you swallow.
Who gets hiatus hernia?

Hiatus hernias are relatively common, occurring in about 10% of the population. Often they
are very small and people who have them don’t know it, as they don’t feel any symptoms or
discomfort.

Most hiatus hernias are seen in

● Adults, > 50y/o.

● Women. (pregnant women)
● Overweight people.
● Smoker.
Aetiology:
Risk factors:

● hereditary factors;
Hiatus hernias can occur when there ● age;
is weakening of the muscle tissue ● obesity;
around the gap where the ● pregnancy;
oesophagus passes through the ● sudden, hard physical exertion,
diaphragm or where this gap is such as lifting;
otherwise stretched. ● a birth defect; and
● trauma or
● surgery to the abdominal area.
Symptoms:
The most common symptoms of hiatus hernia are
those arising from gastro-oesophageal reflux,
These symptoms are often worse when you bend
which can occur as a result of the hernia.
over, lie down or strain to lift heavy objects.

These symptoms include:

Depending on the type of hiatus hernia, other
symptoms can include:
1. Heartburn, which is a painful burning
3. Belching or burping;
sensation felt in the lower front chest area
4. Difficulty in swallowing; and
behind the breastbone and upper
5. Pain on swallowing (especially hot drinks).
abdomen, often after eating or when lying
down; and
6. Chest pain.
2. Regurgitation of sour or bitter-tasting acid
fluid into the mouth, particularly at night,
which occurs with more severe reflux.
Diagnosis:

● barium swallow x-rays or

● upper endoscopy.
Complication:
1. Severe reflux:

A) ongoing reflux》damaging oesophagus》bleeding/stricture》 swallowing difficulty.

B) barrett’s oesophagus.

1. Strangulation: fundus bulges》 twisted/pinched》 bloating/blocked oesophagus/problem swallowing 》 loss blood

supply》ischemic.

1. Difficulty breathing: so much of the stomach protruding up through the oesophageal gap in the diaphragm that it
presses on your lungs and can make breathing more difficult.
Treatment:

★ Aimed at relieving symptoms, sometimes by using drugs and rarely by doing surgery.
OESOPHAGEAL CA
CLASSIFICATION
CLINICAL MANIFESTATION

❖ Dysphagia
❖ Regurgitation
❖ Vomiting
❖ Odynophagia
❖ Weight loss

S&S suggestive of advanced malignancy include:

★ Recurrent laryngeal nerve palsy

★ Chronic spinal pain
★ Diaphragmatic paralysis
INVESTIGATIONS

❏ ENDOSCOPY
❏ CYTOLOGY
❏ CT SCAN
❏ BLOOD TEST
❏ BRONCHOSCOPY
❏ LAPAROSCOPY
MANAGEMENT

➢ Surgical
➢ Radiotherapy
ACHALASIA
● Motor disorder of the distal esophagus caused by degeneration of
Aurbach's plexus

● Pathophysiology
○ autoimmune process causes loss of NO-producing neurons which
normally relax the sphincter muscles
■ association with HLA-DQw1
○ leads to failure of the LES to relax during swallowing
○ results in loss of peristalsis
Symptoms

● dysphagia for solids and liquids

○ usually worse for liquids
● weight loss
Barium swallow
● may show
○ narrowing of the distal esophagus
○ loss of peristalsis in the distal two
thirds
○ dilated proximal esophagus
○ classic "bird's beak" tapering at the
esophageal sphincter
● Manometry
○ most accurate test that may show
■ increased LES pressure
■ inability of LES to relax
■ decreased peristalsis in the esophageal
body
■ diffuse esophageal spasm
● Upper endoscopy
○ useful in excluding secondary causes of achalasia
(i.e. malignancy)
○ use to rule out malignancy
○ shows normal mucosa
● Medical management
○ medications to reduce LES tone
■ nitrates
■ CCBs
■ botulinum toxin injections
■ wears off in approximately 3-6 months
■ requires reinjection
● Surgical intervention
○ endoscopic balloon dilation of LES
■ cures 80%
■ leads to perforation in < 3% of patients
○ myotomy with fundoplication
Diffuse Oesophageal Spasm
Definition

- Loss of normal peristaltic coordination of oesophageal smooth muscle

- Uncoordinated contraction
- Dysphagia

Epidimiology
- Women > men
- Incidence increases in age
- Rare in children
 Clinical features

- Dysphagia
- Chest pain
- Severe spastic pain
- Regurgitation
- Weight loss
History

- Complains of difficulty in swallowing

- Assoc symptoms:
- Chest pain
- Regurgitation
- Loss of weight
- Fever & neck pain (Esophangitis)
- History of cardiac diseases/ respiratory diseases (TRO cardiac chest pain)
- History of neck swellings (thyroid/thyroglossal cyst)
-History of ca (thyroid ca)
Investigations

- Diagnostic
- esophageal manometry (spontaneous activity, repetitive waves, prolonged, high amplitude
contractions)

-Barium enema swallow

(corkscrew esophagus)
Management

Medical
- Calcium channel blockers
- Nitrates

Surgical
- dilatation
- esophageal myotomy
- esophagectomy