DYSPHAGIA

MUHAMMAD ALBAHADILI
MBChB CABS HDLM
CONTENTS OF TODAY’S
CLASS
 Definition of dysphagia
 Swallowing
 Important causes of dysphagia
 What to ask the patient
 Investigations
 Examples causes of dysphagia
Objectives
at end of our lecture we able to:

 Define the dysphagia and differentiate it from other

complaining problems in pharynx or oesophagus
 Describe the swallowing and what are the muscles
involved in it
 List some causes of dysphagia
 Define achalasia and the way of the diagnosis
 Describe the lower esophageal sphincter and the
changes in GORD
Dysphagia
Definition of dysphagia

 Symptom of difficulty in swallowing

 and should be differentiated from;
 Odynophagia: painful swallowing
 Globus: sensation of lump in the throat
 Phagophobia: psychogenic dysphagia
 Regurgitation: reflux of stomach content to
pharynx
 Gagging: food inducing vomiting
swallowing

 It’s a process in which the food and liquid

pass from back of the mouth to the
stomach
• It is an “all-or-nothing” reflex
• It is initiated voluntarily but once it is
started, it cannot be stopped
So what is normal swallowing?

 We can divided the

swallowing in
 Oral
 Pharyngeal
 Oesophageal
MOUTH: PREPARATORY

 LIPS
 TEETH
 TONGUE
 PHARYNEAL PHASE

Nervous Initiation of the

Pharyngeal Stage of Swallowing.
The most sensitive tactile areas of
the posterior mouth and pharynx for
initiating the pharyngeal stage of
swallowing lie in a ring around the
pharyngeal opening, with greatest
sensitivity on the tonsillar pillars.

 TONGUE
 SOFTPALATE
 VOCAL CORDS & EPIGLOTIS
 HYOID BONE & LARYNX
 MUSCLES OF PHARYNX
Oesophagus phase
 Swallowing

 Resting
swallowing

 Voluntary/involuntary?
 What are the cranial
nerves (name the
branch?) involved in the
swallowing?
dysphagia
 Difficulty in swallowing; . It is
not a primary medical diagnosis,
but a symptom of a disease.
 Difficult to move food to pharynx
 “food sticks”; “choking” in
oesophagus
 Normal swallowing
• Oral
• Pharyngeal
• oesophageal

So:
The dysphagia either
• Oral
• Pharyngeal
• oesophageal
Causes:
In the oropharyngeal part
Painful conditions
• Acute tonsillitis
• Glandular fever
• Acute pharygolaryngeal oedema
• Ludwig s angina
Neurological conditions
• Cranial nerves (2nd division of 5th, 9th,10th,11th , 12th ) damage
• post-polio syndrome, multiple sclerosis, muscular dystrophy,
or Parkinson's disease.
• Surgery in neck
• Retropharyngeal abscess
• Pharyngeal pouch
• Tumours oropharynx, hypopharynx
Causes:
In oesophageal part
In the lumen:
• Foreign body
• Drugs
• Gastroesophageal reflux
In the wall:
• Sideropenic dysphagia
• Inflammation
• Tumour
• Motility disorders- achalasia, diffuse oesophageal spasm
• Mallory-Weiss syndrome
• Iatrogenic
• From outside of oesophgus:
• Rolling hiatus hernia
• Retrosternal goitre
• Any mass in the chest
Causes?

Foreign body

drugs

Mass

tumour
Dysphagia
symptoms sign

Difficulty chewing Food spills from lips; excessive

mastication time of soft food; poor
dentition; tongue; jaw or lip weakness.
Difficulty initiating swallow Mouth dryness (xerostomia); lip or tongue
weakness

Nasal regurgitation Bolus enters or exits the nasal cavity as

seen on radiographic swallowing study

Coughing & choking Coughs on trail food ; material enters the air way on
attempts radiographic study

Coughing when not eating Radiographic study shows aspiration of

saliva or lung abnormality

Regurgitation Undigested food in mouth; radiographic

study shows food returning from
esophagus to pharynx or mouth mucosal
irritation on endoscopy
Imp questions to ask?
(History of the disease)
 When did it start?  Any history of
 Solidsand liquids surgery in neck or
from start? chest
 Did it painful?  Dribbling
 Vomiting, Weight loss  cough
 Intermittent/const.a  Regurgitation
nt and progressive  History of stroke or
 Difficult
to make TIA
swallowing  History of
 Any bulge in the neck gastroesophageal
during swallowing reflux
Achalasia
Achalasia
is a primary oesophgeal motility disorder
 Non-relaxing Lower
oesophgeal sphincter
and absent peristalsis
in the body of the
oesophagus
Achalasia: Failure of lower oesophageal sphincter (LOS) to relax

Pathophysiology
 Loss of ganglion cells
[myenteric plexus]
 The cause is unknown, but
may
 Parasitic infection
Trypanosoma cruzi (Chagas
disease)
 5th and 6th decade but
can be in any age
 1/100 000/ year
 Presents with dysphagia,
regurgitation, weight
loss, overspill into the
trachea specially at
night lead to aspiration
presented with cough.
Achalasia
How oesophagus is empting in achalasia?
Why gas bubble is not found in stomach?
What is pseudo achalasia?
Achalasia
Diagnosis:
Radiology

Barium studies
"Bird's beak" appearance and "
megaesophagus,"
Endoscopy
Manometry
• Pressure of LES
<26 mm Hg is normal,
>100 is considered achalasia

• Aperistalsis in esophageal
body
• Relative increase in intra-
esophageal pressure as
compared with intra-gastric
pressure
Therapy of achalasia

 Pneumatic dilatation
 Heller’s myotomy
 Endoscopic myotomy
 Botulinum
 Medication
 calcium channel blockers (nifedipine)
 Nitrates (isosorbide)
Endoscopic treatment
pneumatic dilatation


 Heller’s myotomy
 Botulinum toxin injection
 Botulinum toxin (Botox) is a neurotoxic protein produced by the
bacterium Clostridium botulinum and related species. It prevents
the release of the neurotransmitter acetylcholine from axon
endings at the neuromuscular junction, thus causing flaccid
paralysis.
Diffuse oesophageal spasm:
Incoordinate oesophageal contractions
Hypertrophy of circular muscle fibres
Dysphagia and pain
Pressures on manometry of 400-500 mmHg
Corkscrew oesophagus on barium swallow
Corkscrew oesophagus
 Treatment
 Calcium channel blocker & pneumatic dilatation have only transient
effects
 Surgical management for sever cases
Gastro-oesophageal reflux disease
Gastro-oesophageal reflux disease

Pathophysiology
Investigations
Complications
Treatment
 Lower Oesophageal (Sphincter)
ANATOMY

Mechanisms that prevent reflux:

• High pressure zone (sphincter) Resting pressure of
LOS = 13 mmHg, Length of LOS = 3cm
• The mucosal rosette at the cardia (plug)
• Angle between esophagus and stomach (His)
• Diaphragmatic sling (crura)
• Intra-abdominal length of oesophagus = 2cm (high
pressure area by positive intra-abdominal pr.
 Gastro-Oesophageal Reflux Disease
(GORD)
 Lower oesophageal
sphincter (LOS):
maintain the competent
 LOS transient relaxation
in swallowing, vomiting,
vent swallowed air
 Physiological reflux?
 Pathological reflux?
 relationbetween GORD
and hiatus hernia !
GORD

 acid reflux, is a • Resting pressure of LOS <

condition where stomach 6mmHg
• Length of LOS < 2cm
contents come back up • Intra-abdominal length of
into the esophagus oesophagus < 1cm
resulting in either
symptoms and/or
complications
GORD symptoms
 Classical:
 regurgitation (acid reflux, water brash)
 retrosternal burning
 Epigastric pain radiated to back

Provoked by food (fat, spicy), exercise

In late or sever cases odynophagia developed

 Atypical symptoms: chest pain, asthma, dental

erosion, cough
Investigations

 Inpatients with classical symptoms

the diagnosis can be made clinically

 Olderpatients [with recent onset of

symptoms] require an endoscopy

 Patients with uncontrolled symptoms

(not responded to PPI or dysphagia)
should be investigated
Oesophageal pH monitoring
Endoscopy

Barrett's mucosa

Linear erosion

Dysplasia in Barrett adenocarcinoma

 A normal endoscopy does not exclude GORD (correlation
between symptoms and endoscopy finding is poor)

In patients with atypical or persist symptoms

despite of therapy, oesophageal manometry
and 24 hours pH recording
Note: stop PPI for 1 week before pH recording

The length and pressure of LOS are important

CT scan for anatomy of LOS but not for GORD

Complicated GORD:

Oesophageal stricture

Barrett’s oesophagus
Barrett’s oesophagus
 Columnar transformation of squamous
oesophageal epithelium
 Classical B. (>= 3cm columnar
epithelium
 Short-segment B. (< 3cm)
 Cardia metaplasia (intestinal
metaplasia at gastro-oesophageal
junction without microscopic
changes)
 Precancerous condition ? risk
 Screening intestinal
metaplasia?
 How we can
differentiated
between Barrett or
sliding hernia?
 Treatment:
 GORD treat.
 Proton pump inhibitors
 Ablation of mucosa only for
dysplasia cases
 Laser

 Photodynamic

 Argon-beam

 Plasma coagulation
 Radio-freqeuncy

 Endoscopic mucosal resection

Treatment of GORD

 Reduction of weight, avoid heavy meal late at night, alcohol, smoking, tea
or coffee
 Antacids
 Acid suppressants
 Histamine 2 receptor antagonists
 Proton pump inhibitors
 Endoscopic
 Sutures of gastric mucosa
 Radiofrequency ablation
 Injection of submucosal polymers
 Surgery
 Laparoscopic fundoplication is the most popular
 Surgery

There are many operation for GORD but they are

based on creation of an intraabdominal segment of
oesophagus
Oesophageal cancer
 Squamous and adeno-carcinoma
Squamous cell carcinoma is most common
but the adeno. Is increasing

 Risk factors
obesity
Barrett’s
Smoking
alcohol
 Presented late
 Odynophagia, dysphagia, vomiting,
weight loss are late symptoms,
recurrent laryngeal n. paralysis,
Horner syndrome, supraclavicular
lymph nodes metastasis
investigations

 Ba swallow
 endoscopy
 CT scan
Barium swallow
 CT scan

endoscopy
SUMMARY

 Dysphagia is an important symptom

 Achalasia; GORD; oesophageal cancer
 Careful history and examination
 Not all patients with GORD symptoms need an
endoscopy
 A normal endoscopy does not exclude GORD